|
Business Name: |
|
Address: |
|
City, State, Zip |
|
Country: |
Currently accepting applications
for US ONLY |
Telephone Number: |
|
Fax Number: |
|
|
Type of Ownership: |
|
Title: |
|
Percent Mail Order/Internet |
|
Percent Phone Order |
|
Is your business product or service based? |
Product Service Both |
Explain the type of product or service you
provide: |
|
Amount of Average Sale: |
|
Estimated Monthly Volume:
|
|
Web Site (URL): |
|
Do you currently have Merchant status with any
bank? |
Yes No |
|
First
Name: |
|
Last
Name: |
|
Home
Street Address: |
|
City, State, Zip: |
|
Country: |
Currently accepting applications
for US ONLY |
Email Address: |
|
Date of Birth: mm/dd/yy: |
|
Best Contact Phone: |
|
Best Time To Reach: |
|
Percent
Equity Ownership: |
|
How would you rate your credit? |
|
Credit Card Processing
Options: |
How would you prefer to process your customers' Credit
Cards? |
Standand Credit Card
Terminal PC Software Macintosh Software PLEASE NOTE: For Details On Real-Time Internet Credit Card Processing Click
Here |
|
How soon would you like to get
set up with a merchant account? |
|
Will your product be
downloadable from the Internet? |
Yes No |
Are you operating through a
drop-ship company? |
Yes No |
What additional services would you like information
on? |
Domain
Name Registration Web Site Hosting Shopping Cart
Software For Your Website Graphic Design & Web
Development |
If you have any additional comments or
questions please enter them here.
|
|