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ONLINE REQUEST FORM


E-Mail Address

Web Site URL (if applicable)

Owner/Contact Name

Business Name

Address Suite

City State Zip

Phone Ext. Fax



I am interested in information/literature regarding: (check all that apply)

Processing & Point of Sale Equipment ( I do not currently accept any credit cards)

Processing Only (I am currently accepting credit cards, but would like lower rates)

Point of Sale Equipment (Hypercom, Verifone and or PC Software)

Check Processing Services (Guarantee / Drafting)

Please describe the products and or services your business provides:




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