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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

    Target Markets
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    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)


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