The Internet is a wonderful resource but it lacks the necessary components to develop a strong, sound business relationship. It is from this perspective that we base our contact with you.

Working with you, discovering your needs, discussing the possibilities are reasons why we want to work closely with you and not just toss you a rate and sell you a piece of equipment that ultimately may be unsuitable. If you want a cookie cutter approach to merchant services then we suggest you look elsewhere. If you desire to know more, make informed decisions, be treated fairly, and have a competitive rate structure that benefits your business for a prosperous long term relationship then we welcome you to UPC.

Corporate Name:
Store (dba) Name:
Merchant Contact:
Phone #:
eMail:
Physical Address:
City:
State:
Zip:
Mailing Information:
Address:
City:
State:
Zip:
Phone:
Type of Business:
Type of Ownership:
Sole Proprietorship
Corporation
Partnership
LLC
Average Ticket:
Monthly Credit Card Volume:
Annual Credit Card Volume:
Mail or Telephone Orders:  No  Yes
Mail or Telephone percentage:
Bank Name:
Owned Equipment:
Terminal Model:
Printer Model:
Software Name:
Additional Equipment:

	Yes	No
Do you presently have an American Express merchant account?
Would you like to be set up for American Express?
Do you presently have a Discover/NOVUS merchant account?
Would you like to be set up for Discover/NOVUS?

Existing Processor Discount Rate:
Existing Processor Transaction Fee:
Existing Processor Monthly Statement Fee:
Existing Processor Monthly Minimum:
Existing Processor Chargeback Fee:
Existing Processor Additional Fees:
Additional Comments: