Business Name:____________________________________ 

Owner/Officer:______________________________________ 

Address:___________________________________________ 

City:___________________State:_____________Zip:______ 

Telephone:_________________(please indicate area code)  

Best time to call:________am/pm   Fax:_________________  

E-Mail Address:___________________________________  

Your Homepage URL:______________________________ 

New or Existing Business?________Years in Bus:_______  

How did you hear of our Company?____________________ 

Home Based Bus?______Storefront?______Office?______  

Nature of business and products sold:__________________  

Internet Sales_____%  Phone Sales______% Store_____%  

Estimated Average Credit Card Transaction $___________ 

Estimated Monthly Credit Card Volume $_____________  

Credit History: ___Excellent ____Good ____Fair___ Poor  

Any Bankruptcies in the last 3 years?  ____yes  ____no  

Do you have a  business  bank account?  ____yes  ____no  

  (form currently under construction)