Application Please enable JavaScript in your browser to complete this form.Business Name *Business Location Address *Mailing Address (if different than business)Business Phone *Business Email *Years in Business *Type of Business *Sole ProprietorLLCIncorporatedPartnershipNon-Profit 501c/Tax ExemptOtherCorporate/Legal Name (if incorporated)Corporate Address (if different than business)Corporate PhoneBusiness Category *RetailRestaurantB2BInternet/eCommerceDispensaryLodgingSupermarketGas Station/Car WashCharity/Non-ProfitOtherProducts/Services Sold *Currently Accept Visa and MasterCard? *YesNoCurrent Credit Card Processor Company NameWhat type of equipment would you like? *Stand Alone EMV TerminalMobile EMV Card ReaderPOS IntegrationGateway/Virtual TerminaleCommerceOtherAverage Monthly Credit Card Sales Volume $ *Average Transaction $ Amount *Tax ID / EIN # *Primary Contact Name *FirstLastPrimary Contact Title *OwnerCEOPresidentVPPartnerLLC MemberCFOCOOPrimary Contact % of Ownership (Must be 51% or more) *Residence Address *Primary Contact Date of Birth *Comment or MessageSubmit