PRE - QUALIFY Promo CodeLegal NameDBA/Outlet Name*Contact NameBusiness Phone NumberType of BusinessSole ProprietorPartnershipNon-profitPublic CorporationPrivate CorporationGovernmentCorporate Address Street Address City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code DBA Mailing Address (if different from above) Street Address City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Email* Website Business start date MM slash DD slash YYYY HST NumberBusiness Summary:Please provide a brief summary of your core service and/or product First Principal First Middle Last TitleSocial Insurance NumberDate of Birth (mm/dd/yy) MM slash DD slash YYYY Phone% OwnershipHome Address Street Address City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Choose processing category*Discount Rate PricingiPlus Pricing*Flat Rate PricingEnter MOTO/Internet sales %*Enter Chip & Pin transactions %*POS type (Terminal model)*CLOVER FLEX V3Clover Flex PocketCLOVER MINI V3CLOVER MINI TO MINICLOVER STATION DUOPAX A920INGENICO MOVE 5000INGENICO DESK 5000INGENICO AXIUM DX8000INGENICO AXIUM EX8000Samsung KM24A KioskNewland N910Poynt C CanadaRent/Lease/Purchase*RentLeasePurchasePrice*Notes About the TerminalVisa Volume*MC Volume*Average Credit Transaction Size*All Cash & Card Sales*Visa Credit*Per transaction*Visa Debit*Per transaction*Visa Card Brand Fee*Mastercard Credit*Per transaction*Mastercard Debit*Per transaction*MC Card Brand Fee*Per transaction*Discover/Diners*Per transaction*UPI Debit*Per transaction*Please choose following: Interac Debit Interac Flash Opt IN Add Second Principle? Yes Second Principal First Middle Last TitleSocial Insurance NumberDate of Birth (mm/dd/yy) MM slash DD slash YYYY Phone% OwnershipHome Address Street Address City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Attach Driver’s LicenceMax. file size: 516 MB.Attach Void ChequeMax. file size: 516 MB.Attach Articles Of IncorporationMax. file size: 516 MB.Attach Processing Statements Drop files here or Select files Max. file size: 516 MB. CAPTCHA
