5LINX Payment Solutions

Savvy business owners understand accepting credit cards is a must to maximize revenues and accommodate all types of customers. Its a commodity for business owners. Sign up for 5LINX Payment Solutions and transform a commodity into something more by choosing to support one of our two not-for-profit organizations at no cost to you. The below information will be used by our expert payment processing agents to understand how to best serve you. All information is kept 100% confidential.

o Susan G. Komen for the Cure

o Make-A-Wish Foundation

Please complete the below information. An asterisk denotes a required field.

BUSINESS INFORMATION
Legal business name* Type of business* Legal business address City State Zip Date of incorporation # of locations*

CONTACT INFORMATION
Main business contact / owner* Primary phone* Best time to call* Contact eMail* Are you currently accepting credit cards?* o Current processor Existing credit card terminal (make / model) Existing processing type* o Retail Swipe o MOTO o Online Website o o Leased o Owned YES o NO Average processing volume* Secondary phone Time zone: o EST o CST o MST o PST

Mobile device

5LINX REPRESENTATIVE INFORMATION

5LINX representative name* 5LINX rep. eMail* 5LINX rep. position Primary phone* Best time to call* Direct SVP* Secondary phone Relationship to merchant* RIN number*

Fax this form (and statement if applicable) to: 888.700.6151

An email confirmation will be sent to you within hours of receiving the fax form. Questions? Call 877.526.9365