Business or Individual's Name:
Division, Store Number, or Location:
Amount of Bank Service Charge your business pays for each dishonored check:
Number of cash registers for which you will need Notification Signs:
Approximate number of bad checks you receive per year:
Victim Confirmation - Acknowledging receipt of bad checks processing
Restitution - Restitution checks and confirmation letters
Finalization Notice - Notices of checks returned as uncollectible, cases resolved or otherwise finalized
Other - Miscellaneous communications
Special Handling Requests:
I do not agree to the Merchant Agreement and the terms set forth.
I agree to the Merchant Agreement and the terms set forth.