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* = required field
*
First Name:
*
Last Name:
*
Company Name:
*
Phone:
*
E-mail:
Address:
City:
State:
Zip:
How long has your business been open?
--select--
Less than 1 yr
1 yr or greater
*
How much do you process in Visa/Mastercard from your customers each month?
--select--
Less than $2,500
$2,501 - $5,001
$5,001 - $10,000
$10,001 - $20,000
$20,001 - $30,000
$30,001 - $40,000
$40,001 - $50,000
$50,001 - $60,000
$60,001 - $70,000
$70,001 - $80,000
$80,001 - $90,000
$90,001 - $100,000
$100,001 - $110,000
$110,001 - $120,000
$120,001 - $125,000
$125,000+
How soon are you looking for funds?
--select--
Immediately - 7 days or less
1 - 2 weeks
2 - 3 weeks
3 - 4 weeks
30 days or greater
Have you ever taken money against your merchant account?
YES
NO
If yes, what was the name of the Company?
Have you had any bankruptcies in the past 12 months?
YES
NO
Are you current with your rent with your landlord?
YES
NO
Comments
©2003-2006 Spectrum Merchant Services. All rights reserved. Spectrum Merchant Services is a registered ISO/MSP of Wells Fargo Bank, N.A., Walnut Creek, CA and of BancorpSouth Bank, Tupelo, MS. American Express and Discover require separate approval.
