How are your credit card sales processed?
*
Retail/In Person
Internet/Phone/Mail
What is the average amount of each sale?
*
--- Select One ---
$5-24
$25-99
$100 +
What amount is (or will be) processed per month?
*
--- Select One ---
$500-4,999
$5,000-24,999
$25,000 +
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Does your business currently accept credit card payments?
*
--- Select One ---
Yes
No
Please describe your business and any other requirements for your credit card processing needs?
Email Address
*
First Name
*
Last Name
*
Company Name
*
Phone Number
*
Title / Role
*
--- Select One ---
Administration
CEO/President/ Owner
CFO
CIO/CTO
Consultant
Customer Service
Engineer/Programmer
Facilities/Operations
Finance/ Accounting Manager
Finance/ Accounting Staff
General Manager
Human Resources
IS/IT Management
IS/ IT Staff
Marketing Manager
Marketing Staff
Partner/Principal
Purchasing Manager
Sales/ Business Dev. Manager
Sales/ Business Dev.
Vice President/Senior Manager
Other
Address
*
City
*
State
*
--- Select One ---
Alabama
Alaska
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Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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Idaho
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Nova Scotia
Nunavut (NU)
Nunavut (VU)
Ontario
Prince Edward Island
Quebec (PQ)
Quebec (QC)
Saskatchewan
Yukon
---
Zip/Postal Code
*
Country
*
--- Select One ---
United States
Canada
--------------------
(Unspecified)
Afghanistan
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Algeria
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
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Bouvet Island
Brazil
British Virgin Islands
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Chile
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Islamic Republic of Iran
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Korea, ROK
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Libya
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Luxembourg
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Mayotte
Mexico
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Morocco
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Myanmar (Burma)
Nambia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Norway
Oman
Pakistan
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Lucia
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
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Sierra Leone
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Somalia
South Africa
Spain
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St. Pierre & Miquelon
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U.S. Pacific Islands
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Vanuatu
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Venezuela
Vietnam
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
Employee Size
*
--- Select One ---
1-9
10-19
20-49
50-99
100-499
500+
Industry
*
--- Select One ---
Advertising/Marketing/PR
Agriculture/Forestry
Architecture
Banking/Finance
Biotech/Pharmaceuticals
Business Equipment
Business Services
Construction
Consulting/Research
Education
Engineering
Environmental
Government
Health Care
Hospitality/Lodging/Travel
Insurance
Legal
Manufacturing
Media/Entertainment
Mortgage
Non-Profit
Other
Real Estate
Restaurant
Retail
Shipping/Transportation
Technology
Telecommunications
Website
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