Merchant Account Preliminary Application Information

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Please Provide Available Information

How Did You Hear About Us:    
Business Name:
Owner/Officer:
Years In Business: 
Address:
City, State, Zip:
Telephone:
E-mail:
Your Homepage URL:

Are You a New or Existing Business? New     Existing
Business Type:
Business Location:
Nature of Business:
How Do You Market Your Business?
Describe Products Sold:
Are You Interested in Credit Card Processing For: Internet Commerce     Store Front     Both

Do You Currently Accept Credit Cards? Yes     No
Your Current or Previous Credit Card Processor:
Estimate Average Credit Card Transaction:
Estimate Maximum Credit Card Transaction:
Estimate Monthly Credit Card Volume:

Please Rate Your Personal Credit History:
Any Bankruptcies in the Last 3 Years: Yes     No
Notes or Comments:

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