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Name (DBA)*

Address*

City/Town*

State*

Zip Code*

Email*

Services/Products

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

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