Name:__________________________________________________________
Address: ________________________________________________________
City: ___________________________________________________________
State/Province: _____________________Zip/Postal Code: _________________
Phone: (_____)__________________Fax: (_____)_________________________
Contact Name: _____________________________________________________
Contact Phone: (_____)_______________________________________________
Contact Email: _____________________________________________________
[__] DataPac[__] Direct Network[__] SprintNet
Country Code [3]: ___________________________________________________
City Code or Zip Code [5]: ____________________________________________
Bank ID [6]: _______________________________________________________
Merchant ID [15]: ___________________________________________________
Category Code [4]: _________________________________________________
Primary Authorization Phone: (_____)____________________________________
Alternate Authorization Phone: (_____)___________________________________
Primary Settlement Phone: (_____)______________________________________
Alternate Settlement Phone: (_____)_____________________________________