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All required questions are marked below with a *

Please answer this required question * Does your business currently accept credit cards? Yes No Please answer this required question * Are you currently in need of credit card processing equipment? Yes No Not Sure Please answer this required question * How much do you currently accept, or do you anticipate accepting, in monthly charges? Under $5,000/month $5,000 - $10,000/month $10,000 - $20,000/month $20,000 - $40,000/month $40,000 - $100,000/month Over $100,000/month Please answer this required question * What is, or do you anticipate, the average individual charge amount to be? $1 - $50/transaction $50 - $100/transaction $100 - $1000/transaction $1000+/transaction Please answer this required question * What is/are your most likely method(s) for accepting credit cards? Manually swipe cards at a retail store or rest. Through a website or online business By phone or through mail order Manually swipe cards at mobile bus./trade show Other * Business Name Please provide a business name * Type of products sold or services provided Please provide a type of products sold or services provided *State (in which company is located) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist 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 Please make a state selection Zip Code Please provide a zip code in the format 12345 or 12345-1234 *Contact Name Please provide a contact name *Contact Phone Please provide a contact phone with at least 10 digits *Contact Email Please provide a valid email address Comments