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Terminal Type:
UPS: Red Saver Blue 3 Days Ground Will Call
Purchase Lease Reprogram Lease Transfer Loaner
Merchant Information
Business Name or DBA
Corporate or Legal Name
Location Address
City
State
Zip Code
Telephone
Fax
Contact Name
Cellular Phone
Corporate Address
City
State
Zip Code
Corp Telephone
Fax
Contact Name
Cellular Phone
Federal Tax ID
E-Mail
Web Address
Date Business Started [mm/yy]
Prior Experience (Year)
Grand Open Date
Sole Proprietorship Corporation Partnership Non-Profit
Merchandise/Services Sold
Retail Outlet Restaurant/Food-Tip Restaurant/Food-No Tip Lodging
Mail Order/Telephone Order Supermarket Internet (Real Time) Other
Credit Card Swiped %
Credit Card Keyed
%
Must equal 100%
Owners/Officers
Name
Title
% Ownership
D.O.B. [mm/dd/yy]
SSN
Home Telephone
Home Address
Name
Title
% Ownership
D.O.B. [mm/dd/yy]
SSN
Home Telephone
Home Address
VisaR/MastercardR Qualified Rate
Credit Card/Non Pin Based Debit Card Rate %
Credit Card/Non Pin Based Debit Card Per Item %
Site Inspection
Business Located in Retail Store Front Office/Warehouse Residential Kiosk
Trade Shows Other
Have you physially been on site? Yes No
Service Order
APPLICATION FEE BANKCARD Check Guarantee Gateway      (Non Refundable)
APPLICATION DEPOSIT EQUIPMENT DEPOSIT SECURITY DEPOSIT
  (Refundable within 30 days per merchant request upon approval from bank & leasing company and after equipment installation)
Nurit Hypercom Verifone Eclipse Software
Other
Apply for New American ExpressR Account Yes No
Existing American ExpressR #
By selecting "yes" to Apply for a new American ExpressR account above, you acknowledge that accepting an American Express card for payment is an agreement to the terms and conditions of American Express. Such terms and conditions will be snet to you by American Express.
Apply for New DiscoverR Account Yes No
  By selecting "yes" to Apply for new DiscoverR account above, you will be bound by the US Bank/Nova Informatin Systems Terms Of Service.
Payment Check ACH C Card #
Special Notes:
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