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Referral Form

 
Please fill out your information below.  You will be contacted shortly by the bank's representative Charles Miller with BASYS Processing. 
Business Name (DBA): *
Business Address: *
Business City/Town: *
Business State:*
Business Zip Code: * (5 digits)
Service/Products Sold: *


Type of Business:*
Business Contact Name: *
Contact Phone Number: *
Best Time to Call:
Approx Monthly Credit Card Sales:
Do you currently accept credit cards?*
Yes
  No
How does you process?
 Urgency of Request:*
Normal
  Urgent
Your Email Address: *
Additional Notes: