Registration Form   

Business Information
Business Name
Doing Business As
Street Address
City
State
Zip Code
Phone Number
Merchant Profile 
Type of Ownership   Sole Proprietor
  Partnership
  Corporation
  Other   
Merchant Type   Retail Outlet
  Restaurant/Food
  Home Business, Consulting, Trade Fairs, Outside
       Sales/Service
  Mail/Telephone/Internet Order Only
  Other   
Type of Goods or Service Sold
Number of years in business
Has this business or any associated principal been terminated as a Visa/MasterCard Merchant?   Yes

  No
What services do you already have?
Visa/MasterCard
(If checked, you must submit 3 most current statements)		    Merchant #
American Express    Merchant #
Discover    Merchant #
Diners    Merchant #
JCB    Merchant #
Percent of Credit Cards Swiped
 
Percent of Credit Cards Keyed
%


%
If you have indicated that 20% or more of your
transactions are keyed, complete this section 
Percent Telephone Orders %
Percent Mail/Fax Orders %
Percent Manual Imprint %
What extra services do you want (Visa/MasterCard Included) ?
American Express
Discover
Diners
JCB
Internet / E-Commerce Section
Will you need secure credit card transactions on the internet and a virtual terminal?   Yes

  No
Do you have a web site?   Yes  -  Enter web site URL below

  No
Enter the email address for us to send you our application
Owner Information
Name
Title
Street Address
Shipping Address
City
State
Zip Code
Home Phone
Do you Own or Rent your Home   Own
  Rent
% Equity %
Additional Comments
How did you find our web site or hear about us?