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Let us keep you up to date with trends and special offers that could boost your bottom line.  See our 'What's New' section for the latest edition.
 

 

The following Express Application is not a purchase agreement.
Once received, one of our representatives will contact you directly to answer any questions and complete the application process.  The more information you can provide us now, the better prepared we'll be to meet your needs.

Express Application & Business Profile

   ( = Required Field )
   Business Entity Information
  Name of Primary Contact:   Title:
Phone:  
Alternate Phone:   Type:
Fax:  
Email:  
Your Web Address:  
   
Legal Business Name:  
  DBA Name:  
   
Business Address:  
Address Line 2:  
City:   State:
Zip Code:  
   
Business Type:  
Specify Other:  
 
Business Locations:  Number of Locations:  
   Location Type:
   
State of Incorporation:  
State Where Business License is Filed:  
   
Federal Tax ID #:  
   Use SSN if Sole Proprietorship
   
Business Status:  New Business Existing
  Acquired  Business
 
Business Start Date:
 
Business Acquired Date: 
   
Principal #1:  Ownership Information
   
Name of Principal #1:   Title: 
SSN:   DOB:
% Ownership:   
   
Home Address:  
Address Line 2:  
City:   State: 
Zip Code:  
   
Home Status:    Own Rent   Since Date:
 
Credit:  How would you rate your personal credit?
   Excellent Good Fair Poor
 
Prior Bankruptcy? 
Yes No Type:
Year:
   
Principal #2:  Ownership Information
 
Name of Principal #2:   Title: 
SSN:   DOB:
% Ownership:   
   
Home Address:  
Address Line 2:  
City:   State: 
Zip Code:  
   
Home Status:    Own Rent   Since Date:
   
   Transaction Profile
   
Briefly Describe Your Products & Services:  
   
Avg. Transaction Amt:   (Estimate)
   
 

Bankcard Processing Merchants Only

Bankcard Volume
Estimate: Visa/MC $:
Interval Amount
   
 

ATM, SCRIP & POS Debit/EBT Merchants Only

Estimated Foot Traffic:
Interval Foot Traffic

   
Marketing Mix:  How  do you market your products/services?

(check all that apply)
Should Total 100%

 Face-to-Face Retail

 Face-to-Face Mobile
 Environment

 Mail/Phone Order

 Internet Sales

   

Products/Services
of Interest
(check all that apply)

 Retail/Restaurant Credit Card Processing
 Wireless/Mobile Credit Card Processing
 Offline Credit Card Processing
 for Mail/Phone/Internet Orders
 Real-time Online Credit Card Processing
 for Mail/Phone/Internet Orders
 ATM's, SCRIP, POS Debit/EBT
 for Generating Surcharge Revenue
 Check Processing
 Debit Card Processing
   
Terms of Service:  Lease Purchase Reprogram Existing
   
How Did You Hear About Us?  
 
Comments:  
Referred by:  
    
 
 
 

Toll Free: 1-800-253-9679

 

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