Please complete the form below. If Merchant 1 Payments cannot reduce your monthly processing charges we will pay you $500.

*Name:
*E-Mail:
*Phone:
Company:
Business Type:
Number of Locations:
Address:
City:
Province:	Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Nunavut Northwest Territories Ontario Prince Edward Island Quebec Saskatchewan Yukon
Postal Code:
Fax:
Existing Equipment Type:
Monthly Volume:	0 - $50,000 $50,000 - $100,000 $100,000 - $500,000 $500,000 - and up
Avg Monthly Transactions:
Monthly Processing Charges:
Current Processing Rate:
Referred By: