Contact Name:
     
Phone Number:
     
Fax Number:
     
E-mail:
     
Company Name:
     
Website:
     
Type of Products Sold and Industry Type:
     
Estimated Monthly Dollar Processing Volume:
     
Estimated Average Ticket Value:
     

Please indicate the nature of your payment transactions (check all that apply):
      Face-to-face (card present)
      Mail Order / Telephone Order (card not present)
      Mobile processing on smart phone (iPhone, Android, Blackberry)
      E-commerce

Please indicate your E-commerce shopping cart software or storefront service provider:
     

Please indicate your Point-of-Sale (POS) software (name and version):
     

If you will use a card swipe terminal, please indicate:
      I will need a new card swipe new terminal
      I already have a card swipe terminal (indicate make and model number below):
     

Please indicate any additional needs or special circumstances:
      EBT       Micros       CareCredit       Farm Plan
      Virtual Terminal to submit payment transactions while online with any computer.
      Internet Payment Gateway.
      Enhanced Gateway Features: billing request with link, online payments, buy buttons, shopping cart, inventory management, virtual POS, more...
      Check processing with MICR check reader or check scanner/imager.
      Windows-based software to submit payment transactions using a PC.
      Online reporting capability to view up-to-the-minute account activity.
      Gift Card or Loyalty Card program administration or conversion.
      QuickBooks integration for submitting transactions with QuickBooks.

Please specify if you have multiple locations or any other needs:
     

     
      Thank you!