Company Name

Contact Name

Street Address

City State Zip

Phone Number Fax

E-mail Address

Years in business

Do you currently accept credit cards? Yes No

Are you interested in a Custom Gift or Loyalty card program? Yes No

If yes, what is your previous 12 months volume in Visa and MasterCard charges?

What is your average sale? (in Dollars)

Terminal model or Software used for Visa/MasterCard
(i.e. Tranz 330, Hypercom T7P, IC Verify, etc)

What do you sell?

How do you sell your products? (Please enter percentage for each)
Retail (card-present) %
Mail/Phone/Catalog %
Internet %
Other %
Please Explain

How would you like us to provide you with your formal proposal? E-mail Fax Snail Mail (US Mail)

Is there anything else we should know about your particular business or operations that would impact the accuracy of our proposal?