Thank you for your interest in getting a merchant account through FDIS.  Please complete as much of the below form as possible, and a staff member will contact you shortly.

Contact Information  Name:    Mr. Mrs. Ms. Dr.    Address:       , 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    Contact Numbers:     Home Phone Home Fax Business Phone Business Fax Mobile    Home Phone Home Fax Business Phone Business Fax Mobile    Home Phone Home Fax Business Phone Business Fax Mobile  E-mail Address:     Web Site:      Business Information  Company Name:     Description:   Please describe what your business does and/or sells.  Desired Services:    Visa®/MasterCard®/Discover® Network      Diner's Club®   JCB American Express® TeleCheck®   Gift Cards Business Capital Debit  Monthly Volume:   $   (estimated total of Visa / MC transactions)  Highest Ticket:   $   (estimated highest Visa / MC purchase)  Average Ticket:   $   (estimated average Visa / MC purchase)  Processor:    First Data Non-First Data None   (Do you have a merchant account?)   Comments / Questions  Comments / Questions: