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| Business Name: |
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| Address: |
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| City, State, Zip |
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| Country: |
Currently accepting applications
for US ONLY |
| Telephone Number: |
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| Fax Number: |
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| Type of Ownership: |
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| Title: |
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| Percent Mail Order/Internet |
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| Percent Phone Order |
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| Is your business product or service based? |
Product Service Both |
| Explain the type of product or service you
provide: |
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| Amount of Average Sale: |
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| Estimated Monthly Volume:
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| Web Site (URL): |
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| Do you currently have Merchant status with any
bank? |
Yes No |
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| First
Name: |
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| Last
Name: |
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| Home
Street Address: |
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| City, State, Zip: |
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| Country: |
Currently accepting applications
for US ONLY |
| Email Address: |
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| Date of Birth: mm/dd/yy: |
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| Best Contact Phone: |
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| Best Time To Reach: |
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| Percent
Equity Ownership: |
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| How would you rate your credit? |
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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 |
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| How soon would you like to get
set up with a merchant account? |
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| 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.
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