Prepared for:

Agent: __________________________ Date: ______________________

Phone: __________________________ www.paymentsystemscorp.com
Merchant Questionnaire
Packages
1. Length of time in 2. type of ownership 3. multiple locations? 4. current processor?
Business? (Circle One)
Package A
5. likes/dislikes with current processor? 6. how long with current
processor? Includes terminal

7. retail or moto
merchant?
11. avg. ticket amount
8. current processing 9. business ever file 10. avg. monthly sales volume
solution? bankruptcy?
Qty ____ _____ x $______
12. pci compliant in last 13. corporate affiliations/discounts? best
12 mo.? Package B seller!

Includes terminal and

Does merchant have.... (Circle all that apply): PIN pad
website/shopping cart wireless POS System

Electronic check conversion/guarantee gift cards

Preferred Card Processing Estimate Qty ____ _____ x $______

Current Processor Payment Systems Package C

Volume ______________ Retail _______ % Volume Card Swiped _____________ x ___________ = ______________
Includes terminal, PIN
Avg. Ticket ______________ _______ % Volume Debit Card _____________ x ___________ = ______________ pad, and check reader
# of Trans. ______________ MOTO _______ % Volume Key Entered _____________ x ___________ = ______________
Total Fees ______________ Statement Fee = _____________
Effective % ______________ Equipment = _____________
Qty ____ _____ x $______
Trans. Fee = _____________
Total Fees = _____________
Savings Breakdown with Payment Systems Custom Package
Current Processor Payment Systems Total Est. Mo. Savings
Custom package options include:
________________ __________________ ________________ Gift Cards, Web Gateway, ATM,
Wireless and more.
POS Terminal ____________ Total Estimated Savings 1st Year ________________ *Please contact sales support for
PIN Pad _____________ Total Estimated Savings 3rd Year ________________ custom packages.
Check Reader _____________ Total Estimated Savings 5th Year ________________ Proposal is a worksheet based on information provided by you, the customer, and is intended
to provide a cost estimate only. Proposal is in no manner intended to be a guarantee of sav-
Downgrade Surcharge 2.99 % Retail Each Additional Year Est. Savings ings or charges. Savings may vary based on merchant activity and processing volumes. Rates
________________
apply to pin based debit and qualified card transactions. Additional surcharges apply to
1.99% MOTO
non-qualified or high risk transactions. Additional authorization and/or network access fees
may apply based on transaction type. Please reference Visa and MasterCard merchant rules
Merchant acceptance of terms of estimate x_________________________________ and your terms and conditions for further details.
All rights reserved. Payment Systems Corp. 2010. This material is not to be reproduced or used in
Sales agent approval x_________________________________ any way without the expressed written consent of Payment Systems Corp.