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Corporate Info

Corporate Name*

Position in Company*

DBA (Doing Business as)

Corporate Address*

Corporate Phone*

Corporate Email Address*

E.I.N. / Tax ID #*

Location Name*

Location Address*

Location Phone*

Location Email

Location Contact

Average Debit Ticket

Monthly Debit Volume

Location Time Zone

# of Retail Only Terminals Needed

# of Delivery Terminals Needed

Name

Address

Date of Birth

Phone

Email

Monthly Sales*

Percentage of Sales in Cash

Currently Using Payment Processing?*

Yes

No