Name (First & Last) *

Title *

Legal Business Name *

Legal Street Address *

Legal City *

Legal State *

Legal Zip *

Business Phone *

Business Email *

Business Website Address

--------------------

DBA info to be completed only if different from Legal Business info

DBA Business Name

DBA Street Address

DBA City

DBA State

DBA Zip

--------------------

General Information

Time in business (months & years) *

Do you currently currently accept Credit Cards? *

Your average transaction amount? *

How much money do you expect to collect from credit card sales each month? (Total Dollar Amount) *

How do you process credit cards? *

If you process through a terminal, what percentage of your transaction are swipped?

If you process with a terminal, please provide the manufacturer and model.

If you process with a Payment Gateway, please provider the vendor.

Your First National Bank of River Falls Representative Name (First & Last) *

Contact Us

Sales Assistance:

Telephone:
FAX:

+1 800 917 8026
+1 800 917 8026

Maxx Merchants Support 24/7:

Telephone:
FAX:

+1 888 298 7264
+1 800 917 8026

Maxx Gateway Support:

Telephone:
FAX:

+1 847 352 4850
+1 800 917 8026

Postal Address

Maxx Merchants - Denver 609 E Speer Blvd. Suite 204 Denver, CO, 80203
Freephone:	(800)917-8026
Fax:	(800)917-8026
Email: info@maxxmerchantservices.com