VMS Representative Information

VMS Rep. Full name

VMS Rep. Phone

VMS Rep. Email

Client Information

Business Name

Address

Street Address

City

State

Country

Postal Code

Business Owner / Contact First Name

Business Owner / Contact Last Name

Are you able to make decisions for the business regarding the payment processing and point of sale system? *

Yes

Business Owner / Contact Email *

Best Phone # to reach Business owner / contact on? *

What products or services do they sell? *

Do you have at least $10,000 in monthly card sales? *

Yes

Monthly Card Volume *

Average monthly card volume?

Previous Processing Statement or POS Monthly Sales report

No more than 3 months old

What system are they currently using? *

Wants to pass the card processing fees on to the cardholder using surcharge?

Yes

Unsure at this time

Comments *

Anything else we should know about this merchant?

Photo of storefront including signage with business name.

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