* Merchant Name: (Legal Name of Business)

* Doing Business As Name:

* Contact Name:

Mailing Address:

* City:

* State:
Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
Zip:

* Phone:

Fax:

* Date Business Started with Current Owner:

* Business Format:
   Corporation   Partnership  Sole Proprietorship LLC
Business Description:

* Total Annual Sales: $
* Estimated Visa/MasterCard Annual Volume: $
* Average Sale Per Customer: $
* Total percentage of credit card transactions which are mail order, telephone order or pre-authorized: %

* Do you currently accept MasterCard/Visa? Yes  No
  If yes, do you currently have an electronic terminal? Yes  No
  If yes, please provide terminal type and Serial #
* Do you currently have an electronic Printer? Yes  No
  If yes, please provide the printer type and Serial #
* Do you currently accept American Express? Yes   No
  If yes, please provide American Express SE#
* Do you currently accept Discover? Yes   No
  If yes, please provide Discover SE#
* Your e-mail address: