Merchant Lead Form
Business Name:
Are you a merchant, or are you with a bank?	Bank Merchant
Bank Information
If you are associated with a bank, what is your bank's name?
Who is the contact at the bank?
Merchant Information
If you are associated with a merchant, what bank do you use primarily for day-to-day business deposits?
More Business Information
Type of goods/services sold:
Address:
Suite:
City:
State:
Zip:
Phone:
Fax:
Primary Contact Person:
Phone:
Fax:
Email Address:
How long have you operated this business?
Do you currently accept VISA and MasterCard?	Yes No
Are your sales primarily:	card present? mail/phone order? over the Internet?
Are your customers primarily:	individual consumers? other businesses? government agencies?
Do you currenty own or lease credit card equipment?	Own Lease No