Please complete this form and attach a recent statement if you are currently processing.

1) Is your business located in the United States or Canada?
		United States Canada
2) Does your business currently accept credit cards?
		Yes - We already accept credit cards No - We do not currently accept credit cards or are a new business
3) How do you receive the majority of your credit card orders?
		In Person - Cards are collected directly By phone and/or mail - cards are manually entered Internet - card information is entered by buyer on a website
4) Which types of cards do/would you like to accept?   (check all that apply)
		Visa MasterCard American Express Discover Diner's Club Debit Cards - using pin keypad
5) What is the value of your typical credit card transaction?
		$1 - 19 $20 - 49 $50 - 199 $200 - 999 $1,000 - 4,999 5,000+
6) When would you like this credit card processing service to begin?
		ASAP Within one month 1-3 months 3+ months
9) Do you want information on portable wireless terminals?
		Yes - We would like information on wireless/portable terminals No - We do not need information on wireless terminals

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