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Merchant Account Application Form
Business Name:
Contact Name:
Title:
Business Address:
City:
State:
Zip Code:
Email Address
Phone number:
Best time of day to contact:
9AM - 11AM
11AM - 1PM
1PM - 3PM
3PM - 5PM
5PM - 7PM
7PM - 9PM
EST
Type of account:
Select from the list
Retail/Restaurant
Internet
Mail Order/Phone Order
Hotel
Other
POS System Type:
Select from the list
Software Application
Integrated Restaurant
Electronic Cash Register
Property Management System
Credit Card Terminal
Other
POS System Name:
For example: LimoWiz
System Version:
Does the business currently
accept credit cards?
Yes
No
If Yes, what is the
name of the processor:
Anticipated monthly
VISA/MasterCard volume:
Anticipated average
credit card sale (in dollars):
Anticipated start date
(for new deployments):
Special Instructions
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