Merchant Processing Form

Thank you for considering Liberty Enterprises for your ACH / E-Check Payment Solution. The information you provide will allow us to assess your company as a potential customer. All information submitted will be kept completely confidential.

Contact Information

• Company Name:
  
• Type of Business :
  
• Main Web URL Address:
  
• Contact Person:
  
• Contact Telephone Number:(Please ensure you include the area code and that your number is correct)
  
• Hours of Contact:
  
• Contact Email Address:
  
• Launch Date:
  

Transaction Information

• Have you processed ACH before ?
  
  YesNo
• If so, which company have you processed with?
  
• For how long have you been processing with them?
  
• (Expected) Monthly Amount Processed:
  
• Expected Percentage of Credit Cards by Phone:
  
• Expected Percentage of Credit Cards by Internet:
  

Other Information

• Where did you hear about us?:
  
• Would you like to receive our newsletter?
  
  YesNo
•