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DBA Name (Doing Business As):
Contact Name:
Business Phone:		- -
Business Address:
City:
State:
Zip Code:
Business Email:
Web Site (if applicable):
Type of Business:
Products or services being sold:
How did you find or hear about us?:
Do you currently accept credit cards for this business? No Yes

Owner's First Name:
Owner's Last Name:
Is Your Home and Business Address the same?
Owner/Officer's personal credit?

Estimated Total Monthly Visa/MC Processing Volume (000 format only please):

$.00

Estimated Average Credit Card Sale (per customer) (000 format only please):

$.00

Estimated Largest Credit Card Sale (per customer) (000 format only please):

$.00

How will you process your transactions?

% Through your web site
% Swiping cards through a credit card terminal.
% Manually keyed-in (WITHOUT card imprint)
% Manually keyed-in (WITH card imprint - imprinter required)
100% - Total must add up to 100%

Which product of ours did you want to use to process your transactions?:

Credit Card Machine	Free POS System	Free Cash Register	Smart Phone Swiper	Free Wireless Terminal
Internet Gateway	Yahoo Store	Touch Tone	Other - Don't know

Please enter any comments or questions below: