Merchant Account Inquiry Form

DBA (Business Name)
Legal Name of Business
Contact Last Name
Contact First Name
Title
Address 1
Address 2
City
U.S. State
ZIP/Postal Code
E-mail Address
Day Telephone
Fax
Evening Telephone
Business Website URL
Contact Method	Email Telephone
How did you hear about FDIS?
Are you currently working with an FDIS representative?
No Yes. If Yes, please indicate representative:
Do you wish to process:	Visa^®/MasterCard^®/Discover^® American Express^®

Please call 1-800-574-0633 if you have any questions.