Merchant Quick Application

The information you provide on this form will be treated as confidential. A Xenex account representative will contact you same business to assist you in making s decision that best meets the needs of your business. 　

* Name: * Address * City:	* State: Select State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming * Zip: * Phone: Fax: * E-Mail:
Are You a New Business: Select One Yes No    * Business Name: * Business Type: Select One Corporation Sole Proprietor Partnership LLC Other (Describe below) Other: * Business Location: Select One Retail Store Front Office Building Flea market Residence Other (Specify below)    Other: * Nature of Business: Select One Retail, face to face Restaurant Lodging Mail/Telephone order Internet Describe Products Sold:	* Are you currently working with a Xenex representative?:   Select One Yes No If yes, which representative:      How did you hear about us?   Select One Internet Industry Magazine Referral Other (Specify below)    Other:    Comments:
* Required fields are indicated in red. A Xenex Account Representative will contact you same business day.