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Click on Submit at the bottom of the page when ready to send.
Or if you prefer, call us at 877.737.7355.
Submitted By:
Email address:
Please completely fill out the following pre-approval questionnaire so we may return a response to you promptly. A hard copy of the merchant processing agreement and application (MPA) must be submitted.
Business Information
Name of business or corporation
Who is listed as the legal owner?
Business street address
City, state, and zip code
Business telephone and fax
Home street address
City, state and zip code
Home telephone and fax
Preferred number to reach you
After reviewing our web site, please select one of the following:
Which option are you interested in:
Lease-to-own equipment Purchase equipment Renting equipment Virtual Terminal
Please select which best describes the status of your business:
This is a new Business Existing business not accepting credit cards
Business is currently accepting credit cards I am not in business yet
If you selected "business is currently accepting credit cards, who is your processor?
Select the type of business that you have:
Sole Proprietor Corporation Partnership Other type
If you answered "corporation", above, what state
were the documents filed in?
Briefly describe the type of service or product your business provides. How do you market your service or product?
If your business is on the Internet, what is your web site url?
What is your average credit card ticket? Please estimate an amount
if you are not accepting credit cards.
$1 - $50 $50 - $100 $100 - $500 $500 - $1000 $1000-and up
What is your average monthly credit card volume?
Please estimate an amount if you are not accepting credit cards:
$100 - $1000 $1000 - $5000 $5000 - $10,000 $10,000 - and up
How would you describe your credit?
Excellent Good Poor No credit
Please choose one of the following concerning bankruptcy:
I've never had a bankruptcy Bankruptcy last 1 - 10 years
Bankruptcy last 11 years and up I am involved in a bankruptcy now
Please list 3 Trade References that you do business with.
BusinessName, City, State, a contact and a telephone number or email address.
Any comments?
Please be patient as the form may take a few seconds to submit.
Thank You. We will contact you within 24 hours with pre-approval information.
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