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Business Name and Address Information

Business Name _______________________________________ Mailing and Billing Address (if different) _______________________________________ City/State/Zip _______________________________________ Telephone Number _______________________________________ Years in Business _______________________________________ Time at this location _______________________________________

Merchant "Doing Business As" Name _______________________________________ Location Address _______________________________________ City/State/Zip _______________________________________ Fax Number _______________________________________ # of Locations _______________________________________ Tax ID# (9 digit no.) _______________________________________

Business Information

Type of Business:  Retail  Wholesale  Restaurant  Mail Order/Telephone Order  Seasonal

Merchandise Sold or Service Provided:_________________________________________

Annual Credit Card Volume $___________ Average Ticket $___________ High Volume Month___________

Annual % of VISA/MC Sales Generated through:   MAG Swipe_____% Keyed Manually_____% Mail Order_____% Telephone Order_____% Internet_____% In-Store_____%

( Equals 100% of VISA/MASTERCARD transactions)

Cards Accepted and Equipment Information

American Express  Yes   No Diners Club  Yes   No Discover  Yes   No	Other Cards__________________________________ Terminal Type________________________________ Printer______________________________________
Lease   Purchase   Rental   Reprogram

Owner / Officer

Name____________________________________  Title___________________________________ Address________________________________  City/State/Zip_____________________________ Percentage of Business Owned_______% Has the Owner/Officer ever Managed/Owned/Operated another business that accepted Credit Cards     Yes        No