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Your Name (required)

Your Position in the Company

Your Business Name

Type of Product or Service Offered

Do you currently accept credit cards?
YesNo

Which of the following do you do?
Face-to-Face OrdersPhone OrdersInternet Orders

What is your average ticket?

What is your estimated or expected annual sales volume?

Is your business seasonal
YesNo

If you have a terminal currently, what type is it?

What is the best phone number to contact you?

Do you prefer email contact? If so, what is the best address to contact you?

When would be the most appropriate time to contact you?
Before 10am10am - 12pm12 - 3pmAfter 3pm

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