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Company Name*
Email address*
Phone Number*
Web Site URL*
Sales/Executive Point of Contact*
Sales/Executive Title*
Sales/Executive Phone *
Sales/Executive Email *
IT Development Staff* In-House3rd Party
Development Company Name
IT/Technical Point of Contact
IT/Technical Title
IT/Technical Phone
IT/Technical Email
Current # of Installed and Active Merchants (Applicable to Partners only)
New merchants activated monthly (Applicable to Partners only)
Services requested to integrate Mobile RDCChecks-By-PhoneCheck 21+ACH Debit and/or CreditChecks-By-WebPoint of Sale ChecksReportingBank CardApplication Boarding
Transaction Submission Type* Real-time transaction processingBatch Transaction processing (File)
