Company name  *

Owner/President Name *

Address (Street, City, State and Zip) *

Primary Phone# *

Secondary Phone#

Fax Number#

Email *

Years in business as a POS solution provider *

What US counties do you provide services/sell merchandise to

List POS software you currently sell *

List operating systems you currently sell

List POS hardware you currently sell *

List markets you sell to (examples liquor, grocery etc)

List credit card processing companies you are affiliated with

Describe how you provide on-site and off-site support

List business references