Request a Merchant Account Quote

Please complete the following form:

Merchant statements being faxed?

Yes    No

Note: Please fax all pages of your current merchant monthly bankcard statement.

Merchant Name:

Type of Business:

Decision Maker:

Contact Phone:

Email Address:

Best time to Call:

Location Address:

City:

State:

Zip:

Fax:

New to Cards:

Yes No

Number of Locations:

Years in Business:

Annual MC/Visa Volume:

Average Ticket:

Special Requirements:

Describe the merchandise sold or services rendered:

Accept AmEx

Yes  No

Add AmEx Service

Yes  No

Accept Discover  

Yes  No

Add Discover Service

Yes  No

Accept Diners Club

Yes  No

Add Diners Club Service

Yes  No

Type of Equipment or POS:

Number of units:

   

   

Note: maroon label identifies required information