AMGSP Account Request Form

Account Request

Please Note - This is NOT a Merchant Account Application nor is it a Binding Agreement between yourself and AMG SecurePay. This Form is simply being used to obtain information about your Business and what it is you would like us to do for you and your Company.

Business Name*
Contact Name*
First Name Last Name
Phone Number*
- Area Code Phone Number
City
Business City
State
2 Letter Abbreviation of your Business State
E-mail*
Best Email to Contact You at
Website Address
Business Web Site Address
What Product or Service does your Company sell?
What does your Business do
What Account Type are you interested in?
How will you be Processing your Transactions?
Tell us which AMGSP Product or Feature you are interested in

Virtual Terminal / Payment Gateway Mobile Payments Invoice Program QuickClick Integrated Shopping Cart Customer Vault CertifyPCI™ iSpyFraud™ QuickBooks Export QuickBooks SyncPay Batch Upload Recurring Billing
Does this Business have a Merchant Account

Yes No
Do you need an Account setup Quickly?

Yes No
Would you like to see a Demo of AMG SecurePay™

Yes No Maybe Later
How did you hear about us?

Advertisement Internet Search - Google, Yahoo!, Bing, etc Friend or Family Business Network Social Media - FaceBook, Twitter, LinkedIn, etc Colleague or Co-Worker
Additional Notes
Enter the message as it's shown*
Should be Empty:

AMG SecurePay Contact Info

M - F \| 9 - 5 ET		877.997.9473
24 Hour Support		877.675.2410
Email		Click Here