What is your merchant status
I am not currently accepting credit cards I'm already a Processing Merchant; I want New or Better Services

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
StoreFront MailOrder Trade Shows Door to Door Internet Only Other

Will you physically obtain the credit card from your customer for you to "swipe" the card?
Yes, I'll usually swipe the card! No, card won't be present

Your business is located in
In the U.S. Outside the U.S. - foreign country

Business Address

CityState Zip CHOOSE A COUNTRY USA Afghanistan Albania Algeria Am. Samoa Andorra Angola Anguilla Antigua Argentina Armenia Aruba Ascension Is Australia Austria Azerbaijan Azores Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire Bosnia Botswana Brazil Brit. Vir. Is. Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canary Islands Canada Cape Verde Is. Cayman Is. Centr. Africa Chad Chile China Christmas Is. Colombia Comoros Congo/Brazzaville Congo, Dem Rep Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Diego Garcia Djibouti Dominica Dominican Rep Ecuador Egypt El Salvador Eq. Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Islands Finland France Fr. Antilles French Guiana Fr. Polynesia Gabon Rep. Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenadines Grenada Guam Guadeloupe Guatemala Guinea Guinea Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, South Korea, North Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Is. Mauritania Mauritius Mayotte Is Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Ant Nevis New Caledonia New Zealand Nicaragua Niger Nigeria Niue Island Norfolk Island Northern Mariana Is Norway Oman Pakistan Palau Panama Papua New Gui. Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Reunion Is. Romania Russia Rwanda Saipan San Marino Sao Tome Saudi Arabia Senegal Seychelles Is. Sierra Leone Singapore Slovakia Solvenia Solomon Is Somalia South Africa Spain Sri Lanka St. Helena St. Kitts St Lucia St. Pierre/Miq St Vincent Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikstan Tanzania Thailand Togo, Rep of Tonga Trinidad/Tob. Tunisia Turkey Turkmenistan Turks/Caicos Tuvalu Uganda Ukraine U.A.E. United Kingdom USA Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam USVI Wake Island Wallis West Samoa Yemen Yugoslavia Zambia Zimbabwe

Product or Service Sold

Estimated Monthly bankcard volume:
under $1000 $1K - 5K $5K - 10K 10K- 20K 20K - 30K 30K - 50K 50K - 100K over 100K

Average Ticket amount:
under $50 $50 - $100 $100 - $200 $200 - $300 $300 - $500 $500 - $750 $750 - $1,000 $1,000 - $2,000 $2,000 - $3,000 over $3,000

Type of Ownership
Sole Proprietorship Corporation Partnership LLC Non Profit Organization Other

Merchant Location
Shopping Center Home Based Office Separate building Other ; Do you Own Lease Mo. to Mo. Rent

Owners of Officers Information

Principals Name
;Title

Home Address

CityState Zip

  Do you own or rent?
Own Home Rent Home

How long at current address?
less than 1 yr 1 - 2 yrs. 2 - 3 yrs. 3 - 4 yrs. over 4 yrs.

Home Telephone

Personal Credit History
Excellent Good Fair Poor Collections Past Bankruptcy

If past Bankruptcy, how long ago No bankruptcy - N/A less than 2 yrs. 2 - 3 yrs. 4 - 7 yrs. over 7 yrs.

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:

Smart Phone (With or without Reader)

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 Gateway and Virtual Terminal (for Internet, phone or mail orders)
Reprogram my existing terminal - Model:
Other (specify):

Other Services you are interested in

Web Hosting
Web Design Services

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