Statement Audit Request
Pleaes complete this form for a no cost statement analysis - please email statements to: danny@payprotec.com
Rep Name
Business Name
Name
First Name
Last Name
E-mail
Phone Number
-
Area Code
Phone Number
Type of Business
Please Select
Retail
Restaurant
Ecommerce
Lodging
B2B
Current Equip/Software
Merchant Owned Equip
Please Select
Yes
No
Monthly CC volume
Connection Type
Please Select
Dial Up
Internet
Is this a Free Placement?
Type of Free placement
Please Select
PA Store Front
Free VX520 EMV Term
Free Phoneswipe
Other
Comments - Special Price Request
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Submit
Should be Empty: