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Merchant Services

Please fill in the form below:
Business Name:
First Name:
Last Name:
Company Referral:
Phone:
Best time to call:
Street Address:
City:
State:
Zip:
E-mail:
Type of Business: Retail
Restaurant
Mail/Telephone Order
Internet/E-Commerce
Lodging
Supermarket
Other
Note:
Average Sale:
Monthly Sales:
Products/Services:
Swiped:
Keyed:
Currently Processing: Yes
No
N/A
Need Equipment: Yes
No
N/A
Card Types: Visa
MasterCard
Discover Card
American Express
JCB
Diner’s Club
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