| * Denotes a required field | 
              
              
                 
                Business Name* | 
                 
                Please enter your business name | 
              
              
                | Contact Name*  | 
                Please enter your contact name | 
              
              
                | Address Line1 * | 
                Please enter your address line1 | 
              
              
                | Address Line2  | 
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                | City* | 
                Please enter your city | 
              
              
                | State* | 
                Please enter your state | 
              
              
                | Zip Code* | 
                Please enter your zip code | 
              
              
                | Country* | 
                Please enter your country | 
              
              
                | Phone Number*  | 
                Please enter your phone | 
              
              
                | Fax Number  | 
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                | Internet URL or AOL keyword  | 
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                | Email | 
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                Current or Projected monthly  bankcard $ volume | 
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                Current or Projected AVERAGE  ticket/sale amount | 
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                | The  hard copy of the merchant processing agreement and application (MPA) must be submitted. | 
              
			  
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