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"*" indicates required fields

Name (DBA)*

Address

Zip Code

City/Town

State

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

Upload Merchant Statement

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Name*

Email Address*

Phone Number*

Branch Name*

Cost Center

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