Statement Submittal
DBA
*
DBA Phone Number
*
Expected Close Date
*
-
Month
-
Day
Year
Date
Monthly Processed Volume
*
DBA Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Person
*
Title
*
House or Personal
*
House
Personal
Sales Advisor
*
Industry Type
*
Please Select
Retail
Restaurant
B2B
High Risk
Medical
Field Services
Nonprofit
Auto
eCommerce
Account Type Requested
*
Please Select
Swiped
Moto
Mobile
ECommerce
When is the last time you had your account, and your statements reviewed?
How do you take payments now?
*
Terminal
Virtual Terminal
ACH
Website Pay Now
Website shopping cart
MOTO (Phone)
Mobile
New Acceptor
Would you like to add any of the above to your current workflow?
*
Yes
No
Terminal
Virtual Terminal
ACH
Website Pay Now
Website shopping cart
MOTO (Phone)
Mobile
Have you switched processing companies before?
*
Yes
No
If so, how was that experience?
Why did you switch?
How important is it to give back to your community?
*
Not Very
Somewhat
Important
Very Important
Do you currently use Text 2 Pay?
*
Yes
No
Are they interested in using it?
*
Yes
No
Do you currently send receipts via Text?
*
Yes
No
Are they interested in using it?
*
Yes
No
Do you send out electronic invoices?
*
Yes
No
What is the Invoice Software Name.
*
Do you use ACH currently to take payments?
*
Yes
No
Options:
Through Processor
Through Bank
Do Not Know.
Would you like ACH?
*
Yes
No
Is Invoice integration through QuickBooks important to you?
*
Yes
No
What percentage of your sales are from Consumers vs Businesses?
Consumer
*
Business
*
The total below must equal 100%
Are you still absorbing the monthly credit card fees?
*
Yes
No
Have you considered passing the fees onto the customer?
*
Yes
No
Special Instructions/General Input.
Current Equipment.
Potential Equipment.
Submit
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