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Business Information
Business Name
Tax ID
Email Address
Business Address
City
State --Select State-- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zipcode
Phone Number
Franchise or Locally Owned? Franchise Locally Owned
Guarantor Information
Authorized Contact Name:
Check Box to Confirm: I Confirm I have signature authority
Position in Company? Owner Nonmanager
Social Security Number
Account Information
Business Type Retail Restaurant Heating/Cooling Construction Client Services Other
Description of products/services sold:
Avg. ticket for product or services offered:
Expected monthly credit card sales volume:
If using a POS System, include name of software and version number:
Does your business have a Ethernet or Phone line? --Select Below-- Ethernet Line Phone Line I don't know
Processing History
Is this a new merchant account? Yes No
Name of Last Processor
Contract Termination Issues (*if any)
Recommended Solution
For your needs, we recommend our Flat Rate Program
We recommend the following machine:
NPC Secure
OMNI VX510 DC
OMNI VX 510
Optimum M4230
NPC Mobile Card Reader
Additional Options
Do you own this recommended machine? Yes No
If no, then I would like to purchase it ($) I would like to rent it ($ / month)
Number of Machines Needed?
Additional Options:
Click Below to Lock in your Rate Today!
4%
Flat Rate
$0
Down
Month
No Contract Fee!
No Cancellation Fee!
Terms of Service: By submitting this form, you agree to allow Retriever of Jackson, Inc. to create a formal application for credit card processing. The information submitted hereby will only be used for this purpose and will not be shared with any third parties. Furthermore, you agree and consent that a sales representative of Retriever of Jackson, Inc. will contact you via email or phone to discuss this information.
TOS Agreement I agree to the Terms of Service
By clicking the submit button below, you are simply submitting your information to our sales rep. You are NOT agreeing to any contract or terms of agreement.
One of our sales reps, pictured to the left, will be in contact shortly.
*This offer valid through this web site only.
-Linda Collett, Steppin' Out
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