Company : Contact : Address : Suite # / Apt # : City / State : , AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY : postal code :   Phone : ( )   -  Email :

Please tell use your anticipated Credit Card Sales Information? (If you currently accept Credit Cards, please enter numbers based on your last (2) two statements.)     # of Transactions:     Monthly Volume : $  .00 Average Ticket : $  .00 High Ticket : $  .00

Are you currently accepting credit cards? Yes      No     Please choose the types of credit cards you currently accept Visa MasterCard AMEX DISCOVER DINERS CLUB FLEET CARDS EBT / FOODSTAMPS     Credit Card Rate : .0 % (Example: 165 = .0165 = 1.65%) Transaction Fee : $      (Example: .26 = $0.26) Statement Fee : $      (Example: 10 or 10.00 = $10.00) Other Fees : $      (Example: .10 = $0.10)     Are you currently accepting debit cards? Yes      No Debit Fee : $      (Example: .65 = $0.65)     Are you currently accepting checks? Yes      No Please choose the type of Check Acceptance Check Authorization Check Gaurantee Check Conversion None of the Above     Check Fee : $      (Example: .65 = $0.65)

If you currently accept credit cards, please tell us what percent of your transactions fall into the below categories?     % Visa/MC : % % Other : %  (AMEX, DISCOVER , DINERS CLUB) % Debit : %   % Total