Company Information
Business Name
Physical Business Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District
of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New
Hampshire
New
Jersey
New
Mexico
New
York
North
Carolina
North
Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode
Island
South
Carolina
South
Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West
Virginia
Wisconsin
Wyoming
Zip Code
Contact Telephone Number
Office Telephone Number
Fax Number
Please Tell Us About Your Business
Type of Business
Retail
Store
Home-Based Business
Mail or Phone Order Business
Wireless Business / Onsite
Processing
Internet Business/Shopping
Cart
Flea
Market
Restaurant
Grocery
Store
Convenience Store
Mall
or Kiosk
Financial Institution
Other
Type of Merchant
Accepting Credit Cards for
the 1st Time
Existing
Merchant
Website Address
Email Address
Credit Card Processing Needs
Average Ticket Size
$100
or Less
$100
- $500
$500
- $750
$750
- $1000
$1000
or More
Monthly Credit Card Volume
Less than $5,000 Volume
$5,000 - $10,000 Volume
$10,000 - $25,000 Volume
$25,000 - $50,000 Volume
$50,000 - $100,000 Volume
$100,000 & More Volume
Equipment / Service Needs - skip if you have no equipment needs
Terminals & Printers in One
Nurit
2085
Nurit
2085 Plus - Internal Pin-Pad
Nurit
2085U - Internal Battery
Nurit
2090
Nurit
3010 - Wireless / Mobile
Nurit
3020
Verifone Omni 3200
Verifone Omni 3210
Hypercom
T7P
Hypercom
T77
Hypercom
T7Plus
Hypercom ICE 5500+
Talento
Talento with Pin-Pad
Tranz
420
Tranz
460
Omni
3750-Dial Only
Omni
3750-Dial/Ethernet
Terminals
Tranz
330 - New
Tranz 330 - Refurbished (Track
1)
Tranz 330 - Refurbished (Track
2)
Tranz
380 - New
Tranz 380 - Refurbished
Tranz
380x2
Zon Jr XL - Refurbished
Nurit
2080
Nurit
2080 Plus
Hypercom
T7E - New
Hypercom T7E - Refurbished
Hypercom
T7Plus
Hypercom
T8
Pin Pads & Check Readers
Verifone
1000
Nurit
252
Nurit
202
Hypercom
S8
Mag-Tek MICR Mini - Check
Reader
Wireless/Phone Service
Phone
Service
SmartPhone
- Wireless/Mobile
Nurit
3010 - Wireless/Mobile
ComStar Wireless Pager
Nurit 8000
Software
PCCharge Pro
PCCharge Express
Internet Payment Gateway
Internet / Web Site
Cart Manager
Internet Payment Gateway
e-Commerce Enabled Web Site
& Acceptance
Virtual Terminal
Ownership Information
Owner Name
Business Entity
Sole
Proprietor
Partnership
Corporation
Limited Liability Corporation
Owner Home Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District
of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New
Hampshire
New
Jersey
New
Mexico
New
York
North
Carolina
North
Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode
Island
South
Carolina
South
Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West
Virginia
Wisconsin
Wyoming
Zip Code
Home Phone
Other
Purchase Options
Purchase with credit card
Purchase by company/personal check
Purchase by ACH checking withdrawal
I want to lease my equipment
How did you hear about us?
Internet
Postcard
Mailing
Yellow
Page Ad
Referred by An Existing Merchant
Other
Search Engine Directory
Sales Rep Name
Have not spoken with
a Sales Rep
Bill
Johansen
Dick
Chandler
Paul
Bogdan
Cindi
Stanley
Angel Alford
Kenny
Roon
Tom
Nelson
Daniel
Gargulio
Jack
Chevalier
Jana
Motyka
Natalie
Bryn
Paige
Labozzo
Regina
Lannomico
Sharon
Kratz
Special Instructions?
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