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    Name of Entity (Legal Name)

    City

    State / Province

    Telephone # (Landline)

    Business Site URL

    Corporate / Billing Address

    Country

    Postal Code

    Email ID:

    How Long in Present Business? (Years / Months)

    Authorised Contact Name

    Visa/Mastercards

    Card Swipe

    E-Commerce

    Average Ticket

    VISA / DISCOVER / MASTERCARD Monthly Volume

    Amex

    AMEX Monthly Volume

    High Ticket

    AMEX Average Ticket

    Opt out of AMEX Marketing Communication

    MO/TO QUESTIONNAIRE

    1.What percentage of sales are to: Business Clients?

    Individual Consumer?

    2.Method of Marketing

    Other

    3.Ecommerce Merchants - % of customer base:

    %US

    %Canada

    %Other

    4. Visa/Mastercard/Discover card sales are charged to the card on:

    if Other (Specify):

    5. Do you require deposits?

    If yes, % of total sales:

    OR Flat fee:

    Is Final payment due before fulfillment?

    If yes, how many days before final delivery?

    6. Does any of your billing or marketing strategy involve negative response, or automatic billing?

    If yes, explain:

    7. Do you offer a product/Service Warranty or Guarantees?

    If yes, is it

    8. If Refund, is it:

    Other

    9. Does your business charge recurring billing to customers?

    10. Does your business offer up-sells?

    If yes, please provide the company names associated with the up-sells:

    11. How is the card payment information entered into the payment system?

    Other.

    12. If credit card payment information is taken over the Internet is payment channel encrypted by SSL or better?

    13. Do you own the product/inventory?

    Is the product stored at your business location?

    If No, where is it stored?

    14. Who ships the product?

    Contact Name:

    Phone Number

    Zip

    Plus4

    City

    State

    Street Number

    Street Name

    Unit Designator

    Unit/Suite/Apt/Floor

    15. Method of Delivery

    If Other:

    16. How long after payment is product delivered?% of Sales in Same Day

    % of Sales in 1-3 Days

    % of Sales in 4-7 Days

    % of Sales in 8-14 Days

    % of Sales in 15-30 Days

    % of Sales in 30+ Days

    Merchant Certificate #

    Certificate Issuer

    Expiry Date