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Basic Merchant Information

Company Name: *

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Company Website: *

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Contact Phone Number: *

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Contact Name (First/Last:) *

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Email Address: *

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Merchant Type: *

Referred By:

Please give a detailed description of your products and/or services:

Merchant Financial Information

Monthly Sales Volume: *

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Transactions per Month:

Average Ticket:

Current Chage Back Ratio:

Please list all current and previous processors:

Merchant Checklist

Retail Swipe

ACH

Cash Advance

Other

Does the merchant have an existing Merchant Account?

Yes

No

Does the merchant have an affiliate program?

Yes

No

Does the merchant outsource product fulfillment?

Yes

No

Does the merchant have 24/7 customer service?

Yes

No

Does the merchant use reoccurring billing?

Yes

No

Does the merchant need a shopping cart?

Yes

No

Does the merchant use inbound/outbound telemarketing?

Yes

No

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Please complete our inquiry form. An e-commerce engineer will evaluate and respond within one business day.