MERCHANT ACCOUNT PRE-APPLICATION (Note: Items in red are required) Please fill out the following information about your business and we will contact you within 24-hours: Contact Name Business Name Business Address City State (U.S. Only) Select a State Alabama Alaska Alberta 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 Business Phone Fax Mobile Phone Best Time to Call Website Address (If any) Email Address Please tell us about how you will be accepting credit cards: Type of Merchant --None-- Retail/Card Swipe Mail Order/Phone Order Internet/Shopping Cart Equipment/Software Needs Equipment Software Needs Credit Card Terminal - No Printer Terminal with Thermal Printer Terminal and PinPad Terminal and Check Reader Terminal, PinPad, & Check Reader Transaction Manager Software Cellular Credit Card Terminal Internet Payment Gateway Average Ticket Size Average Ticket Size $100 or Less $100 - $500 $500 - $750 $750 - $1000 $1000 or More Average Monthly Volume Projected 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