Elsa Maria
Partnership Sales
Dallas, TX   (214) 849-3656
Chase Paymentech
214.849.3653  
CPI system Desk Top
Merchant Application
Merchant Application
Business Information:
Owners Information:
Company Name:

DBA / Outlet Name:

Contact:

E-mail:

Company address:

( no P.O.Box )


Work Phone:

Type of Business:

Product / Services Sold

Federal Tax ID #

Number of Employees:

Ethernet Connection:



Owner / Officer Name:

D.O.B.

Home Phone:

Cell Phone:

Home address:







Notes:
Elsa Maria,  Partnership Sales
Dallas, TX   (214) 849-3656
elsa.lorenzo@chasepaymentech.com