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Business Contact Name
*
First
Last
Please Provide Your Full Name. (Required)
I am…
*
— Select Choice —
Owner
Decision Maker
Employee
Other
Business Email
*
Provide Best Email – Required.
Business Phone Number
*
Required
Business Name
*
Required
Main Industry
*
Restaurant
Retail
Health Care / Wellness
Automotive
Grocery
Service
Other
What Type of Business are You?
Website / URL
If no website, let us know if you are interested in help making one.
Business Address
*
Address Line 1
Address Line 2
City
— Select state —
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
How Do You Currently Accept Payments?
In Store / Card Present
Online / eCommerce
Invoices
Mobile / On-the-Go
Keyed
ACH
New Business – Not Currently Processing
Other
Preferred Processing Method
*
Simple Processing
Cash Discount
Surcharging
Dual Pricing
I Am Not Sure
Other
Required
Do you Use a Point of Sale System? If So… Which?
Currest Estimate of Your Monthly Credit Card Processing
Average Transaction Amount
What are Your Current Rates?
What Rates are You Looking For?
What Do You Need and Want? (check list of features)
*
Tap-to-Pay on Phone
Mobile Card Reader
Online Payment Gateway
Virtual Terminal
Recurring Billing / Subscriptions
Invoice / Pay-By-Link
Next-Day (or faster) funding
Chargeback Support Tools / Fraud Protect
POS integration
Inventory Management
Employee Management
Customer Receipts (Text/email/ Print)
Loyalty / Rewards Program
Reporting / Analytics
Custom App
Website
AI Marketing Videos
AI Voice / Phone
Other – See Bellow – Provide Detail
In the next two boxes, outline what you must have and what you want.
Features You Must Have?
What Features are the Most Important to You?
Website Do are
Features You Want?
Tell us anything and everything that would help your business.
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