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Referral Information Form

Referral Information
DVCU Contact Person:
Referring DVCU Branch:

Merchant Contact Information
Merchant Name (DBA):*
Business Physical Address:
Business City, State, ZIP:
Service/Products:
Contact Person:
Business Phone:*
Business Fax:
E-mail Address:

Business Profile
Business Structure:
Merchant Type:
Owner's Name:
% of Ownership:
%
Does the business currently accept credit cards?
yes no
If "yes," for how long?
% of business done via telephone, mail order or internet:
 %
Additional Comments:

Submit Information

 

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