Online Request Form

Name:*
Email:*
Phone:*
Address:*
City:*
State:*
ZIP:*
Business Name:*
Type of Business:* RETAIL
RESTAURANT
HOTEL/LODGING
INTERNET
MAIL ORDER/TELEPHONE ORDER COMPANY
OTHER*
If OTHER Please Specify:
 
 
Credit, Debit, and Private Label Card Processing
Please fill out this section if you would like more information about processing credit, debit, or private label cards.
 
How will you process transactions?: SWIPED TRANSACTIONS
MANUALLY KEYED TRANSACTIONS
INTERNET
 
Are you currently processing credit, debit, or private label cards?: YES
NO
Annual bankcard sales (or projected):
Average Ticket (or projected):
Do you want to accept online debit: YES
NO
 
Do you need credit/debit/private label card equipment?: YES. I WILL NEED TO PURCHASE/LEASE EQUIPMENT
NO. I HAVE EQUIPMENT TO REPROGRAM OR I HAVE AN INTERNET ACCOUNT WITH GATEWAY
Please enter model name and type of POS system/POS equipment or name of gateway:
 
ATMS
Please fill out this section if you would like more information regarding Automated Teller Machines.
 
I am interestd in: CARD/PAY PLACING AN ATM IN MY BUSINESS
LEASING/PURCHASING ATM
PROCESSING WITH CARD/PAY WITH MY EXISITING ATM*
Enter make and model of ATM:
 
 
Please enter the text you see:

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