MERCHANT ACCOUNT QUESTIONAIRE

Please fill out the following short questionaire We will contact you by the next business day. This is a free service and there is no cost or obligation. Required fields are denoted with an asterisk (*)

Please note: This information you provide is held in strict confidence and is never sold, rented, or shared with any other business or third party.

BUSINESS INFORMATION


Business Name *:
Business Address *:
City, State, Zip Code *:
Business Phone *:
Business Fax *:
Web Site Address:
Type Of Business *:
Business Start Date (MM/YY) *:
Please describe products or services sold in a few sentances *:
Do you currently process Credit Cards *:
Estimated monthly card sales volume *:
Estimated average ticket price *:
Order sources? (total must equal 100%):	Retail Internet/Mail/Phone
Please rate the owner's credit:

CONTACT INFORMATION


Contact Name *:
E-mail Address *:
Best numbers to reach you at *:
Best time to call *:
Time Zone:
How did you find us:

PROCESSING OPTIONS


Please check all of the items below that you are interested in.
Point of Sale Terminal
Software
Authorize.Net Internet Processing
Have my own processing equipment (please specify type)	Type:
Unsure
Notes or Comments: