** Type of Payment Method:
** Type of Account required:
Name of Business:
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Contact Name:
 *
Contact Email:
 *
Business Address:
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State/Province
:
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Zip/Postal Code:
 *
Daytime Phone:
 *
Business Fax:
 *
Legal Name of Business:
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Principal Owner:
 *
Type of Product or Service Sold:
 *
Age of Business:
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** What credit cards do you currently accept ?:
Who is your current processor:
 *
Indicate Monthly Visa and MasterCard volume:
 *
What is your average sales ticket:
 *
What is your website url:
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Which country are you incoporated in?:
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What percent is your monthly chargebacks?:
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** Direct or 3rd Party Account (new business):
Comments:
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