Inquiry Form



	Employees

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Free Processing Evaluation


	*Please indicate what services you are interested in (Select all that apply):*


	Credit Card Processing

	Check/ACH Processing

	Gift/Loyalty Processing


	High Risk Account

	Third Party Accounts

	International Acquiring


	*Business Information:*

	Company Name:

	Doing Business As:

	First Name:

	Last Name:

	Company Address:

	Province /City:

	Postal Code /Zip:


	Business Phone:

	Cell Phone:

	International Ph:

	Fax:

	E-Mail:

	Website:

	State:

	Country:


	*Business Profile:*

	Business Type:

	If other:

	Years in Business:

	Does your business currently accept credit cards?

	How much do you currently accept, o anticipate accepting, in monthly charges?

	How do you plan to process credit cards? (Select all that apply)


	Yes

	No

	Under $5,000 monthly

	$5,001 - $10, 000 monthly

	$10,001 - $20,000 monthly

		$20,001 - $40,000 monthly

		$40,001 - $100,000 monthly

	Over $100,001 monthly

	Retail / POS

	Internet / E-Commerce

	Wireless

	Manually Swiped


	Are you a new Business?

	Are you currently in need of credit card processing equipment?

	What do you anticipate to be your average individual ticket amount?


	MO/TO (Mail Order / Telephone Order)


	Yes

	No

	Yes

	No

	$1 - $50 per transaction

	$51 - $100 per transaction

	$100 - $500 per transaction

	$500 - $1,000 per transaction

	$1,000 + per transaction


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