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NPS sales agent name (if any)

Your Business Name

Contact Name

Address

City

State

AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip code

Contact telephone number

Fax number

Email address

Web site address

How did you hear about us?

Type of business and/or products sold:

Do you already accept credit cards?

please select one yes no

If you answered "yes" to the previous question, for how long have you accepted cards...

...and what is your estimated amount processed annually?

In which NPS services are you interested? (select as many as you wish)

Credit Card Processing
PIN-Based Debit
Electronic Check Processing

Gift Loyalty Programs
Short-term Capital Financing
All of the services

How did you hear about us?

please select one Referral Search Engine Green Sheet Transaction World Banner Ad Other

If you were referred, by whom?

Questions/Comments

Preferred method of contact

Email Telephone Mail Fax None

Best Time of Day to Call

Morning Afternoon N/A

Would you like to have an NPS information package shipped to you?

No Yes