Merchant Questionnaire - To be filled out and submitted at time of pro forma or application.

1. Merchant Profile Questionnaire
To be completed by Sales Agent and provided with merchant statements
1. Merchant Name____________________________________________________
2. Sales Agent Name__________________________________________________
3. Number of Locations__________________________
4. Current total number of terminals per location________________
5. Terminal Type (select one)
○ Internet (Virtual Terminal)
○ Dial (phone cable)
○ Wireless (no cable)
○ Datawire/IP (ethernet cable)
○ Other________________
6. If processing credit cards on internet, what gateway and supporting software do they
use? (ex. authorize.net, quickbooks, eProcessing, etc.)__________________________
______________________________________________________________________
7. If processing credit cards on Internet, is merchant billed directly by gateway or
processing software company?_____________________________________________
8. Terminal(s) brand and model number (ex. Verifone Vx510, MICROS e7, FD100,
etc.)__________________________________________________________________
9. Terminal(s) owned or leased?______________________
10. Does current processor have early termination fee?__________ if so, $__________

2. 11. Do they want their terminal to auto close, or batch manually? __________ If yes,
what time? ____________________
12. Do they want to accept PIN debit? _____________ If yes, do they have a
compatible PIN pad or do they need one?____________________ PIN Pad make and
model_________________________________________________________________
13. Do you have a check reader, or require a check reader?_____________ If yes,
what is the make/model of your check reader?________________________________
14. Are there any other needs regarding 3rd
party software or integrated applications?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
15. Is there anything else NEXTEP Processing will need to know before setting up their
accounts?
______________________________________________________________________
______________________________________________________________________
_____________________________________________________________
16. Contact person for the download:________________________________________
Best contact number: ____________________________________________________
Contact email: _________________________________________________________
Application Checklist:
____ Signed and Completed Merchant Applications
____ Voided bank check from account where debits/deposits will be made
____ Signed confirmation page
____ Merchant Profile Questionnaire