Merchant Processing Form

Thank you for considering Liberty Enterprises for your ACH / E-Check Payment Solution. The information you provide will allow us to assess your company as a potential customer. All information submitted will be kept completely confidential.

Contact Information

• Company Name:

• Type of Business :

• Main Web URL Address:

• Contact Person:

• Contact Telephone Number:(Please ensure you include the area code and that your number is correct)

• Hours of Contact:

• Contact Email Address:

• Launch Date:

Transaction Information

• Have you processed ACH before ?

  YesNo

• If so, which company have you processed with?

• For how long have you been processing with them?

• (Expected) Monthly Amount Processed:

• Expected Percentage of Credit Cards by Phone:

• Expected Percentage of Credit Cards by Internet:

Other Information

• Where did you hear about us?:

• Would you like to receive our newsletter?

  YesNo