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Your Contact Information * Required Field * First Name: * Last Name: * Job Title: * Company: Address: Address2: * City: State/Province: Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory * Country: Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Cte d'Ivoire Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakstan Kenya Kiribati Kuwait Kyrgystan Lao Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia (FYR) Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands United States Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe * Phone: (Outside U.S. & Canada, please include Country Code) Fax: * Email: Website URL: * My Business is: (Select all that apply. Hold CTRL (PC) or CMD (Mac) to select more than one). Choose One or More Retail Wholesale / Distribution Direct Marketing Financial Services Government Agency Other 2. Program Information * Required Field * Programs: (Select all that apply. Hold CTRL (PC) or CMD (Mac) to select more than one). Choose One or More Payroll Only Payroll & Commission Commission Only Direct Marketing Corporate Travel Card Procurement Card Gift Card Loyalty Card Student Card * Services: (Select all that apply. Hold CTRL (PC) or CMD (Mac) to select more than one). Choose One or More Electronic Payments Bill Payment Bank Payment Services NxPay® Payment Platform Merchant Processing Prepaid Debit Cards Program Management * Number of Monthly Transactions: Choose One Less than 1,000 1,000 to 5,000 5,001 to 10,000 10,001 to 25,000 25,001 to 50,000 Greater than 50,000 * Objectives: (Select all that apply. Hold CTRL (PC) or CMD (Mac) to select more than one). Choose One or More Employee Focused Provide New Employee Benefit Customer Focused Increase Customer Acquisition/Loyalty Reduce Costs Increase Sales / Revenues Increase Direct Deposit Increasee Tracking / Reporting Capabilities Locations that we do business in: (Select all that apply). USA South America Australia Canada Caribbean New Zealand Mexico Europe Asia Central America Africa Other 3. Additional Information Have a Program: Yes, we have a payment platform Yes, we have a merchant processor Yes, we have a prepaid provider Yes, we have a bank payment provider Message: How did you find us:
