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Electronic Check Conversion
ADDITIONAL LOCATION INFORMATION
Location Name: 
Address: 
City: 
State:  Zip:   
Location ID: Location Contact: 
 
Days/Hours of Operation:
(Week Days) Open:  Close:  Business Phone:   
(Saturday) Open:  Close:  Home Phone:   
(Sunday) Open:  Close:  Fax:   
      E-mail:   
POS Terminal: (Brand/Model) 
Is the Merchant currently processing credit card transactions from this terminal? 
MICR: (Brand/Model) 
Printer: 
Purchased:  Leased:  Other:    From:   
        Contact:   
Location Name: 
Address: 
City: 
State:  Zip:   
Location ID: Location Contact: 
 
Days/Hours of Operation:
(Week Days) Open:  Close:  Business Phone:   
(Saturday) Open:  Close:  Home Phone:   
(Sunday) Open:  Close:  Fax:   
      E-mail:   
POS Terminal: (Brand/Model) 
Is the Merchant currently processing credit card transactions from this terminal? 
MICR: (Brand/Model) 
Printer: 
Purchased:  Leased:  Other:    From:   
        Contact:   
Location Name: 
Address: 
City: 
State:  Zip:   
Location ID: Location Contact: 
 
Days/Hours of Operation:
(Week Days) Open:  Close:  Business Phone:   
(Saturday) Open:  Close:  Home Phone:   
(Sunday) Open:  Close:  Fax:   
      E-mail:   
POS Terminal: (Brand/Model) 
Is the Merchant currently processing credit card transactions from this terminal? 
MICR: (Brand/Model) 
Printer: 
Purchased:  Leased:  Other:    From:   
        Contact:   
 

Please review information before clicking 'Print Form'