Please fill out the form to submit a Merchant Services Referral. Referrals marked as “Normal” will be responded to within 48 hours. Referrals marked as “Urgent” will be responded to within 24 hours.

"*" indicates required fields

Name (DBA)*

Address

City/Town

State

Zip Code

Email*

Contact Name*

Contact Phone Number*

Best Time to Contact Merchant

Approx Monthly Credit Card Sales

Does the client currently accept credit cards?*

Yes

How does the merchant process?

Is the merchant a client of the bank?

Yes

Urgency of Request

Normal

Urgent

Upload Merchant Statement

No file chosen

Max. file size: 100 MB.

optional

Referrer Information

Name*

Email Address*

Phone Number*

Region

Branch Name*

Branch Name

Please recap your conversation with this prospect

Name

This field is for validation purposes and should be left unchanged.

Thank you for partnering with Basys!

Referrer Information