Premiazos Lead Form

Sales Representative Information

Sales Representative Name *

Department or Division *

Email *

Phone *

Employee Number *

Special Notes

Client or Business Information

Contact Name *

Business / Organization *

Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

Business Hours *

Annual Revenue

Industry Type *

City *

State *

Email *

Phone *

High Risk *

(If YES; who authorizes the Request?)

How long doing business? *

Previous experience with POS Service *

Monthly Sales Volume (Count and amount) *

Chargabacks (Count and amount) (copy) *

Business Inspection (Always is required) *

Neighborhood Conditions *

Good
Bad
Regular

File Upload

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Comments and/or Additional Instructions

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Premiazos Lead Form

Sales Representative Information

Sales Representative Name *

Department or Division *

Email *

Phone *

Special Notes

Client or Business Information

Contact Name *

Business / Organization *

Annual Revenue

City *

State *

Email *

Phone *

Message