INQUIRY FORM

We compliment you on your choice to expand your customers’ payment options to include acceptance of credit cards, ATM/debit cards and checks.

With regards to servicing the specific needs of each and every merchant it's important that we know a few things about your business. This information will allow us to give you the best discount rate possible.

Please fill out the form below and a FDIS representative will contact you within one business day.

For immediate assistance call: 818-575-9728

Fill out this form completely.
Status	Please select your title Mr. Ms. Mrs. Miss
Legal Name
DBA Name
Last Name
First Name
Address 1
Address 2
City
U.S. State	Please select your state ALASKA ALABAMA ARKANSAS AMERICAN SAMOA ARIZONA CALIFORNIA COLORADO CONNECTICUT District of Columbia DELAWARE FLORIDA GEORGIA GUAM HAWAII IOWA IDAHO ILLINOIS INDIANA KANSAS KENTUCKY LOUISIANA MASSACHUSETTS MARYLAND MAINE MICHIGAN MINNESOTA MISSOURI MARIANA ISLANDS MISSISSIPPI MONTANA NORTH CAROLINA NORTH DAKOTA NEBRASKA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEVADA NEW YORK OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VIRGINIA VIRGIN ISLANDS VERMONT WASHINGTON WISCONSIN WEST VIRGINIA WYOMING
ZIP/Postal Code
E-Mail Address
Day Telephone
Evening Telephone
Contact method	E-Mail Telephone
How did you hear about FDIS?
Are you currently accepting credit cards
No Yes
If yes, what type of volume are your currently processing in MasterCard and Visa transactions?
Average ticket:
Method of acceptance?	Keyed Swiped
Point of Sale System:	Software Hardware / Terminal Online / Internet
Are you currently working with a FDIS representative?
No Yes—please indicate representative