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First Name: Last Name: Business Name: Address City: State Zip Fax: ex: 123.456.7890 Telephone: ex: 123.456.7890 E-Mail Address: (If Applicable) Your Homepage URL: What is your Average Per Item sales amount? What would you estimated your monthly sales volume to be? Business Location: Select From List  Select From List  Home based  Retail store front  Trade shows  Restaurant  Commercial office  Swap meet  Flea market  Kiosk  Medical or Professional  Nature of Business: Select From List  Internet  Mail order  Telephone order  Retail, face to face  Service, field sales  Other  Describe Products Sold: How Do You Market Your Products or Services? Select From List  Internet  Magazines  Flyers  Store Front  Yellow Pages  Network Marketing  Referral, word of mouth  Other  Are you currently working with a Representative? No Yes Please check programs and services of interest Select From List  Virtual Terminal ACH New Equipment Mobile Equipment Check Guarantee Services Refurbished Equipment Trade-in / Upgrades Free Analysis / Quote Other  How did you hear about us? Select From List  Brochure in the mail  Yellow pages  Bank referral  Merchant referral  Other  Other: Notes or Comments: Please submit this form and you will be contacted by New Accounts, ASAP!

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