Discount Pay

First name *

Last name *

Email *

Phone *

Fax Number *

Legal Name of Business *

Business Street Address *

Business Suite # (if applicable) *

Business City *

Business state *

Business Zip Code *

Merchant Website *

Select Merchant *

Owner Information

Owner's First name *

Owner's Last name *

Home Phone *

of Ownership *

Home Address *

Home Apartment (if applicable) *

City *

State *

Zip *

Owner Date of Birth (mm/dd/yyyy)

Card Charging Policies? *

Type of Ownership *

Year Business was Started *

Card Charging Policies? *

Return and Refund Policies *

Total Monthly Credit Card Sales (estimated): $ *

Average Individual Credit Card Sale Amount (estimated) $ *