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www.ePaymentNow.com - Inquiry Form

ePaymentNow.com^® Inquiry Form

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Please complete this form as accurately and completely as possible.

Section 1 and 2 must filled completely otherwise your form won't go through.
Please recheck your entries prior to submitting this form.

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Section 1 - Company Information

Company Name:
Industry:
Mailing Address:
City, State, Zip:	,

Section 2 - Contact Information (Primary)

Primary Contact:
Title (Position):
Department:
Phone/Extension:	Ext.
Fax:
E-Mail Address:

Section 3 - Miscellaneous Information

Company Website:
Electronic Check currently in use on Website? Yes No
Total Number of Locations (If Applicable):
Annual Number of Returned Checks:
Monthly Number of NSF Checks:

Section 4 - Interested Services

Indicate below the services prospective client is interested in: (check all that apply)

eRecoveryNow™ Electronic Check Conversion™
eChecksNow Payments Gateway™
eChecksPhoneNow™ Pre-Authorized Checking Check Verification
Credit Cards ePaymentNow eBillingNow

Section 5 - Current Operations

Annual Sales ($):
Percentage of Sales Paid by Check (%):
Average Dollar Per Sale ($):
Current Credit Card Processing Fee (%): % Per Transaction Fee ($):
Current Charge for Credit Non-Swipe Transactions ($):
Number of Credit Card Terminals Per Location:
Terminal Model #:
Printer Model #:
Micro Reader Model #:
Is Client Using Verification for Checks at this time?: Yes No If Yes, Company Name:
If Applicable, fee per transaction ($):
Is Client Using a Company for NSF Recovery?: Yes No If Yes, Company Name:
How much is charged per returned item by client's bank?:

Section 6 - Additional Comments

Additional Comments:

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