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Bank of Franklin County
Merchant Services Referral Form
Merchant Information
Name (DBA)
*
Address
Zip Code
City/Town
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Email
Services/Products
Contact Name
*
Contact Phone Number
*
Best Time to Contact Merchant
Don't Know
Mornings
Afternoons
Evenings
Weekends
Anytime
Approx Monthly Credit Card Sales
Never Accepted Credit Cards
$0-5,000
$5,000-10,000
$10,000-25,000
$25,000-50,000
+$50,000
Don't know
Does the client currently accept credit cards?
*
Yes
No
How does the merchant process?
Terminal
Software
Point of Sale System
Online Shopping Cart
N/A
Don't know
Is the merchant a client of the bank?
Yes
No
Urgency of Request
Normal
Urgent
Upload Merchant Statement (optional)
Drop files here or
Accepted file types: jpg, gif, png, pdf.
Referrer Information
Name
*
Email Address
*
Phone Number
*
Branch Name/Location
*
Cost Center
Please recap your conversation with this prospect