High Risk Merchant Lead Submission
Sales Agent Name *
Company *
First Name *
Last Name *
Phone *
Email
Merchant Industry
Please select one
Automotive
Chiropractic
Coaching
Consumer Goods
Consulting
Cosmetic Surgery
Dental
Ecommerce
Electronics
Funeral
Furniture/Mattress
Home Improvement
Jewelry
Medical
Medspa
Restaurant
Travel
Veterinary
Vocational
Other
Street Address 1 *
Street Address 2
City *
State *
Postal Code *
Current Setup
Visa
MasterCard
Discover
American Express
Debit
Gift Cards
Loyalty Cards
EBT Food Stamp
Fleet Cards
HSA Cards
JCB / UnionPay
Check Guarantee
ACH
Average Monthly Volume
Average Ticket
Highest Ticket Size
Number of Locations
Current Processor
Equipment Type
Equipment Ownership
Please select one
New Sale
Free Placement
New Rental
Merchant Owned
Merchant Leased
How Would You Rate Your Equipment
Please select one
Poor
Average
Great
Merchant Needs
Faster Processing
Next Day Funding
Better Tech Support
Local Agent
New Terminal
New POS Software
Mobile Payments
Contactless Payments
New ATM Machine
Gift & Loyalty Cards
Ecommerce
Check or ACH Services
Business Loan or LOC
Consumer Financing
Payroll
Other / See Notes
How Would You Rate Current Processor
Please select one
Poor
Average
Great
Reasons for Considering Change
Rates
Service
Technology
Agent
How Soon Are You Looking To Change
Please select one
Today
This Week
Within 30 Days
Within 90 Days
Unsure
Current Provider Cancellation Fee Amount
What Do You Like Best About Current Provider?
What Would You Change About Current Provider?
Will Have Statements Ready
Yes
No
Notes *
Submit