Business Name  

Name Of Owner  

Email Address  

Phone Number  

Do you currently have merchant services & payment processing?

Yes

No

What type of merchant services & payment processing do you currently have?

POS Hardware

Computer Software

Mobile Phone

Online / E-Commerce Gateway

N/A

Please list name and model numbers of each device you currently have:  

What payment plan are the devices you listed above currently on?  

From the devices you listed above, how are your payments usually processed?

Over Internet

Over Phone Lines

In U.S. Dollars, how much do you process in credit cards per month?  

How often do you batch and settle your credit cards per month?  

What is your current chargeback ratio percentage?  %

Are you accepting all major credit cards?

Yes

No          If not, which ones are not accepted? 

Do you currently have monthly fees?

Yes          If yes, how much are your monthly fees?  

No

Are you seeing non-qualified transaction fees on your merchant statements?

Yes

No

How are your transactions entered?

Swiped / Chip

Manually Keyed In

Both

Interested in enabling to receive tips?

Yes

No

What made you choose your existing processor and what do you like about it?  

Is there anything you want changed on your existing processor or any problems you want solved?  

What other payment processing options have you tried?  

In a perfect world, what would you like out of your payment processor?  

Are you currently in talks with other competitors?

Yes           If so, which ones? 

No

Have you ever been terminated or been on a TMF list for your merchant account?

Yes

No

Is there anything else we should know?
(G2 Scan & Background Checks will be done for an underwriting decision)