Payment Acceptance Solutions for Your Business
  (877) 397-3127
Merchant Quote
Please be advised that this is a preliminary quote.  The nature of our business requires us to find out more information on how your business transacts before we can give a formal quote.  If you are currently using a processor please fax your last month's statement to 636-552-4713 to receive a more accurate quote.
Merchant Quote

Please enter the appropriate information into this form.  We will contact you to verify the information and submit a formal Quote to approve your application and get you processing!
Applicant Information
Contact Name:
Merchant Name::
Address:
City:
State:
Zip Code: (5 digits)
Email::
Merchant Information
Are you currently accepting Credit Cards?
If Yes: Monthly Visa/MC/Disc volume?
Average ticket ?
Please provide Your Effective Rate:
( To get your effective rate please
divide your total processing cost, including fees, by your monthly Credit Card sales.):
Please provide a percent of processes face to face compared to over the telephone or internet?
Other Information
Comments:

ReliantPay, Inc. ~ 14280 Manchester Rd. ~ St. Louis, MO 63011 ~ (636) 220-7255

ReliantPay is a registered ISO/MSP of Wells Fargo Bank, N.A., Walnut Creek, CA 

American Express requires separate approval.