"*" indicates required fields

Select What Applies to You*

I am a Banker Completing this Form on Behalf of a Merchant.

I am a Merchant Completing this Form for Myself.

Business Name (DBA)*

Address*

City/Town*

State*

Zip Code*

Contact Name*

Contact Email*

Contact Phone Number*

Best Time to Reach Out*

Is the Merchant a Client of the Bank?*

Yes

What Was the Source of this Client Referral?*

Does the Merchant Currently Accept Credit Cards?*

Yes

Approx. Monthly Credit Card Sales

How does the Merchant Process?

Your Name*

Your Email Address*

Your Phone Number*

Branch Name*

Upload Previous Processing Statement

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 100 MB.

If you do not upload statements here, please make sure you have them ready when we reach out.

Please provide any additional information.

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