Lease to own your merchant account equipment, software, and shopping cart system for only $39.95 per month! WE GUARANTEE APPROVAL no matter what your credit status may be! The benefits include: * 2% Discount Rate * No Monthly Minimum Billing Fee * No Statement Fee if No Sales Made for the Month * Money Available in 3 Business Days * Windows-Based or Macintosh Compatible Credit Card Processing Software (Available) * Shopping Cart System To Take Orders Securely Right On-Line (Available) * Checks By Fax/Email/Phone software. Please call us at 912-236-6676 for more information. Please fill out the form below and fax to 970-927-0964. ======================================================= Merchant Account Application Legal Business Name: ____ State: __________________ DBA: ____________________ Business Address: _______ Suite: __________________ City State Zip: _________ Describe Business: ______ Business Hours: _________ Percent Mail Order: _____ Percent Phone Orders: ___ Percent Trade Show: _____ Locations: ______________ Year Started: ___________ Fed Tax ID: _____________ State Tax ID: ___________ Principal Contact: ______ Title: __________________ Phone No: _______________ Fax No: _________________ Est Card Sales Month: ___ Average Ticket: _________ Type of Business: _______ State Incorporated: _____ Age of Business: ________ Date Acquired: __________ OWNER PRINCIPAL INFORMATION: President Owner: ________ Title: __________________ Ownership: ______________ Residence Address: ______ City State Zip: _________ Own Rent: _______________ Since: __________________ Home Phone: _____________ Previous Address: _______ DOB: ____________________ CO OWNER INFORMATION: Co-Owner: _______________ Title: __________________ Percent Owned: __________ Residence Address: ______ City State Zip: _________ Since: __________________ Own Rent: _______________ BUSINESS TYPE: Type of Building: _______ Found EMS By: ___________ CREDIT INFO: Rank Your Credit: _______ Prior Bankrupt: _________ Year: ___________________ TERMINAL: Prefer PC Software or Terminal?: ___ Terms/Lease or Purchase?: __________________ REFERENCES: BUSINESS REFERENCES: (Please list three)