Merchant Services Rate Quote Request

Have a question?

Please fill out the following form to receive a free rate quote and information about Central National Bank’s Merchant Services Program.  Please keep in mind that this is not an application for services and it is not in any way a legally binding document. Upon submission of this form, a representative will be in contact with you either through email or phone with the price quote and additional information.

Legal Name:   

DBA Name:   

Contact Name:   

Contact Phone Number:   

Contact Email Address:   

Is this a seasonal business:    No Yes

Type of Ownership:   Sole Proprietorship LLC Partnership Public Corporation Private Corporation Non-profit Organization Other

Business Type:   Retail Restaurant Lodging Service Internet MOTO Business to Business

Have you ever accepted credit cards:    No Yes

If yes, processor’s name:   

Please check the boxes of the card types you will accept:

All Visa/MC/Discover Cards    Visa/MC Debit Cards Only    Dincers/Carte Blanche    JCB    American Express    PIN Based Debit Cards

Do you expect to accept Corporate or Purchase Cards:    No Yes

Projected average credit card transaction:   

Projected average monthly sales:   

Please fill in a projected percentage for accepting credit cards by processing method*:

            Electronic card-swiped transactions:    %

            Electronic hand-entered (with imprints):    %

            Electronic card-not-present (w/o imprints):    %

            Touch-tone in person (with imprints):    %

            Touch-tone card-not-present (w/o imprints):    %

*total for these options must equal 100%; please use only the options that you feel you will use

Will you want to manually batch your transactions? Yes No

            If no, what time would you like for the terminal to auto-batch?     A.M.    P.M.

If % of transactions without imprints is greater than 20%, please answer the following:

            Do you bill your customers prior to goods being shipped:    n/a No Yes

                        If yes, how many days:    n/a 0 - 2 days 3 - 30 days 31 - 60 days 60 - 90 days Over 90 days

            Do you use a third party fulfillment house:    n/a No Yes

Submission Information:

I certify that I am 18 years of age or older.  I understand that this is not a guarantee of approval for a merchant services account.  I also certify that everything I have stated on this form and any attachments is correct. Central National Bank may keep this form whether or not any services are eventually provided.

Additional information or comments that you would like us to have in considering your application: