Name (First & Last) Business Name (Federal Tax ID Number) EIN (If any) Business Address City/State/Zip Code Website Address How many years in business Type of business Select Sole owner Home Based Partnership Corporation e-mail (needed to get back to you) Telephone (needed to get back to you) Fax (needed to get back to you) Name of primary owner Home address State/City/Zip Code Date of Birth Country What type of Products Services do you offer? Does your business sell adult goods or services (including escort agencies and sex chat-lines)? No  Yes Are you a telemarketing company who sell through outbound/inbound calls? NO  Yes Does your business sell gambling services (including lotteries, raffles and competitions)? No  Yes Does your business sell any products or services related to travel, tourism, tours, timeshares, or hotel room bookings? No  Yes Monthly processing needed? Select $5000 $10,000 $20,000 $50,000 $100,000 + What is your average sale? Do you currently process credit card? No  Yes Have you ever processed credit card before? No  Yes How will you process credit cards? Select Face to Face Phone/Mail Order Internet MLM Memberships Do you currently own any equipment, software, payment gateway  to process credit cards? NO YES How were you referred to Payquickly? Please specify which search Engine, yellow pages, direct mail etc. It helps us keep track of our advertising. Thank you. Additional Comments Note: Information provided in this form is never divulged to any outside parties, sold or rented and is held in the strictest of confidence.  Upon Completion of this form a Consultant will get back to you shortly