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  Part I: Contact Information
 
  Please complete all fields in this section.  
 
  Your Name

Phone (include area code)

Fax (include area code)

Email

 

Company Name

Web Address

 

   Mailing Address

Line 2

City

State

Zip

  
 
 
  Part II: Questionnaire
 
  Please answer all questions in this section.

1. What is the nature of your interest?

I am a business and want to sell my products and services online.
I am an Independent Sales Organization or value-added reseller and want to sell transaction processing solutions based on iPOSS.
I am an Internet Service Provider or Web Hosting provider and want to lease e-commerce stores to merchant customers.
I am a website developer or interactive agency, and would like to offer commerce-enabled websites to my customers.
I am a software developer and want to integrate my software with iPOSS.
I am a systems integrator and want to offer sophisticated enterpise-level transaction processing solutions.
Other (please specify):


2. How soon would you like to begin referring our service?



3. Who will you be referring to us?



4. How many merchants do you anticipate signing up each month?



5. How did you hear about VERIFY ONLINE?


 

  
 
 
  Part III: Comments or Questions
 
  Use the space provided below for any comments or questions you would like to add at this time.

Additional Comments or Questions

 

  
 
 
  Part IV: Submit the Form
 
  Once you have completed this form, press the 'Submit' button below to finish the signup process.