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What is your merchant status
Business Name
E-MAIL Address (Required! - Please Enter Only ONE email address.. try not to use a Yahoo.com email address as Yahoo email is not very reliable.)
Your home page web address, if any
Date Established
Business Telephone
Fax Number
Method of Selling
Will you physically obtain the credit card from your customer for you to "swipe" the card?
Your business is located in
Business Address CityState Zip
Product or Service Sold
Estimated Monthly bankcard volume:
Average Ticket amount:
Type of Ownership
Merchant Location ; Do you
Owners of Officers Information
Principals Name ;Title
Home Address CityState Zip
Do you own or rent?
How long at current address?
Home Telephone
Personal Credit History
If past Bankruptcy, how long ago
How did you find our web page?
What search keywords did you use, if any?
Cards you want to accept:
Credit Cards
Discover
American Express
Debit/ATM
Gift Cards
Check Service you want:
Select Check (traditional Check Guarantee)
Electronic Check Conversion (Accept checks just like a credit card!)
Check Authorization Only (not check guarantee)
iChecks Pro (mail/ fax/ internet check processing)
How do you want to process the payments you receive:
Nurit 8000 Wireless Terminal (Credit and Debit Cards)
Mobile 5000 Wireless Terminal (Credit Cards AND Checks!)
Desktop Terminal to Swipe cards and/ or checks (for Retail Stores)
Online Virtual Terminal (for phone or mail orders)
Online Gateway (to connect website store for Real Time authorizations)
Reprogram my existing terminal - Model:
Other (specify):
Other Services you are interested in
Web Hosting
Web Design Services
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