Merchant Referral Form


Thank you for your interest in Global Merchant Services.
Fill out your information as accurate as possible and someone will contact you during the time of day specified.

 

 

I am currently interested in:

 

To make multiple selections, hold down the CTRL button while selecting.

 

 

Company and Contact Information

 

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Business Name:
Business Type:
No. of Years in Business:
Business Address 1:
Business Address 2:
City:
State: form Zip Code:
Business Phone:
Business Facsimile:
Alternate Number:
Website Address:
Contact Name:
Contact Phone Number:
Contact E-mail:
Comments: 

 

Sales Information
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Merchant Type:
Products/Services Sold:
Sales Profile: % Swiped
% Manually Keyed
% Mail Order / Internet
Comments: 
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Projected Sales Volume
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Average Credit Card Ticket:   Credit Card Monthly Volume:
 
Average Check Ticket:       Highest Monthly Check Volume:
 
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Merchant Account Information
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Do you currently accept credit cards?
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If so, who is your current card processor of bank?
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Discount Rate %:
 form Transaction Fee:
 form Monthly Min:
 form Statement Fee:
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Are you paying a Flat Fee for Check / ATM Debit Cards or a Discount Rate?
Do you currently have check guarantee?
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If so, who?
ATM Machine Account Information:
Are you in need of an ATM Machine?

Lease      Purchase (Cash or Credit Card)     FREE ATM Placement
Surcharge Amount Desired: Number Of Locations:
Foot Traffic Per Hour: How Many Hours Opened Per Day: How Many Days Opened Per Week:
Would you like Parts, Labor and Supplies as a Service Contract for your ATM Machine?
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Comments:

Miscellaneous Information
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How did you hear about us?
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Sales Office/ Affiliate Name: Reference I.D. Number:

 

Date:

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