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Agent Reference Materials
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Please complete and click Submit Form at the bottom of this page
Please enter "N/A" for any required field that doesn't apply to your business.
Company Name:
Doing Business As:
First Name :
Middle Name :
Last Name :
Company Address :
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone :
Cell Phone :
Home Phone :
Cell Phone :
Other Phone :
Fax :
Email
Website Address :
Please provide password if site is under construction or password protected:
Business Type :
Select Business Type
Adult Sites and Products
Attorneys/Legal Services
Auto Rental
Bail Bondsmen
Buy/Shopping Clubs/Wholesale Clubs
Casinos/Gaming/Sportbook/Lotteries
Cellular Phones & Beepers
Check Cashing Services
Coin Shops
Collection Agencies
Computer Store
Contractors
Detective Services
Door-to-Door Sales
Downloading of Software
Escort Services/Massage Parlors
Fireworks Stores
General Warehouses Storage
Gravestone/Monuments
Gun Shop
Hair Restoration Services
High Volume/High Ticket
Home/Apartment Operated Business
Horoscope/Fortune Tellers
Industrial Supplies
Infomericals
Insurance Products
Investment Opportunities
Jewelry Sales/Repair
Kiosks
Freezer
Mortgage Service/Securities Sales
Multi-level Marketing
Lounges
Outbound/Inbound Telemarkting/Phone Solicitations
Pawn Shops
Pharmaceuticals/Vitamins
Educations
Home and Auto
Taxis/Limousines
Telecommunications Equipment Sales
Ticket Sales
Time Share Sales
Travel
Used Auto Sales
Water Purifiers
Weight Loss Centers
About Business:
Country of incorporation:
New or Established Business:
Estimated Monthly Volume:
Average Ticket:
Average Ticket:
Highest Ticket:
Have you ever processed credit cards before?:
Yes
No
If you answered Yes above please indicate your current processor:
Reasons for requesting this account?:
TMF (violation of merchant agreement or outstanding balance)
Low Credit Score (less than 500)
Capped Volume
New Business
High Chargebacks (Include monthly%)
How do you process or plan to process credit cards?:
Retail
Wireless
Moto
Internet
Other (please specify)
Are you interested in:
ACH
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