Merchant Services Questionnaire

Please complete the following questionnaire if you would like a representative to contact you with additional information on merchant card services:

* indicates a required field

Business name: *

Business Address: *

Url:

City: *

State: *

Zip Code: *

Contact Name: (Last,First) *

Email Address: (Email) *

Phone Number: *

Website Address: *

Are you a member of PMCU? *
Yes
No

Annual Sales Volume: *

Average Ticket/Sale Amount: *

Do you have current Merchant processor? *
Yes
No

If so, who is your processor?

Referred By? *