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Lead Submission Form

Required Information

Sales Agent Name *

Payroll or ERC Lead Submission *

PayrollERCBoth

Company *

First Name *
Last Name *

Phone *

Email *

# of Employees *

Payroll Frequency *

Additional Information (Not Required)

Merchant Industry

Street Address 1
Street Address 2
City
State
Postal Code

Number of Locations

How Would You Rate Current Processor

Reasons for Considering Change

How Soon Are You Looking To Change

What Do You Like Best About Current Provider?

What Would You Change About Current Provider?

Notes