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How Did You Hear About Us?

Other:

First Name

Last Name

Your Email

Your Phone

Company Name

Street Address

City, State/Province, Postal/Zip Code, Country

Description of products or services

Web Site URL(s)

Primary Method of Acceptance
Web / online sales (e-commerce)MOTO / call centerPoint of Sale (Retail)

Target Markets
USAEuropeAsiaLatin AmericaOther

Do you currently accept credit cards?

How long have you been accepting credit cards?

Current Payment Service Provider(s)

Monthly Credit Card Total Sales Volume
(If you are a startup, please use projected figures)

Average Single Transaction

Highest Single Transaction

Are you looking for payment options besides credit cards?

Additional Comments (special requirements, shopping cart or CRM platform used, etc)