Form

First Name*

Last Name*

Phone Number*

Email*

Title

Company

Type of Business

Address Line 1

Address Line 2

City

State

Postal/Zip Code

Province/Region

Country

Fax Number

Best time to call

Do you currently accept Visa or MasterCard?

Yes No

Average dollar amount for Visa and MasterCard transactions

Approximate dollar amount of your average monthly volume in Visa and MasterCard transactions

Do you accept checks?

Yes No

Average number of monthly check transactions

Are you a member of one of our partner associations?

Yes No

Please type the association below

Description or make and model of current processing equipment/software

Which products and services are you interested in? (Please check all that apply)

Credit Card Processing ACH/eCheck Processing Recurring Payments Web-based Payment Processing Remote Check Deposits Automatic Check Recovery Mobile Transactions Gift & Loyalty Cards Saving Money

What would you like to change about your current processing?

If you like, please tell us a little more about your business