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merchant account services
What is/are your most likely method for accepting credit cards?
Manually swiped cards at any retail store
Manually swiped cards at a restaurant
Manually swiped cards at a fast food restaurant or coffee shop
By phone or through mail order
Manually swiped cards at a mobile business or trade show
Other
How much do you currently accept, or do you anticipate accepting, in monthly charges?
Under $5,000/month
$5,000 - $10,000/month
$10,000 - $20,000/month
$20,000 - $40,000/month
$40,000 - $100,000/month
Over $100,000/month
What is, or do you anticipate, the average individual charge amount to be?
$1 - $15/transaction
$15 - $50/transaction
$50 - $100/transaction
$100 - $500/transaction
$500 - $1,000/transaction
$1,000+/transaction
Business Name(DBA):
Products/Services Description:
Contact Name:
Mr.
Mrs.
Ms.
Dr.
Rev.
Telephone Number:
-
-
Ext:
E-mail:
Address:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip/Postal Code:
PC America Salesperson:
Martin Sheridan
Ken May
Tony Scarpa
Ryan Christman
Kevin Scott
Katia Urrico
Sam Kahan
David Gosman
Todd Nash
Ralph Frascone
Comments:
Retail POS
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Restaurant POS
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POS Software
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POS Hardware