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Merchant Account Application Inquiry Form
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Referring Institution
MERCHANT CONTACT INFORMATION MERCHANT ACCOUNT INFORMATION
Bus. Name:   Currently accepting credit cards? Yes No
Contact Name: Expected annual Visa/MasterCard sales volume:
$
Address: Average ticket amount: $
  Card Present (Swiped): % , Not Present (Keyed) %
City: Date business started:
State: Zip: Description of products or services sold:
Bus. Phone: ( ) - ext.
Home. Phone: ( ) - Additional comments/instructions:
Cell. Phone: ( ) -
Email:
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