Merchant Processing Assessment to Accept Credit Cards

Thank you for considering Liberty Enterprises for your Internet credit card Payment Solution. This form will allow us to undertake a rapid business assessment of your company as a potential customer. All information is completely secure and will only be used for the purposes of assessing your application.

Contact Information

• Incorporation Name:
  
• Location of Incorporation:
  
• Business Type:E-commerce, Pharmaceutical, etc.)
  
• Main Web 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:
  

Transaction Information

• Are you currently processing with credit cards?
  
  YesNo
• If so, which company have you processed with?
  
• (Expected) Monthly Amount Processed:
  
• Maximum Single Transaction:
  
• Current Chargeback %:
  
• Total Credit Card Sales Volume for the Last 12 Months:
  
• Expected Percentage of Credit Cards by Phone:
  
• Expected Percentage of Credit Cards by Internet:
  

Other Information

• How do you market your website?:
  
• Would you like to receive our newsletter?
  
  YesNo
•