Please submit information about your company if interested in offering PaymentNet services to your customers.
CSP/Web Host Info Form
Contact Information:
Parent Company Name:
ISP dba Name:
Domain Address:
Address:
City:
State:      Zip:
Sales/Marketing Contact:
Phone:
Fax:
Email:
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Technical Contact:
Phone:
Fax:
Email:
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Platform (OS) used:
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# of hosted domains:
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# of hosted merchants or approx %:
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Approximate number of hosted merchants with real-time payment-enabled Web sites:
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# of new Merchant sign-ups last month:
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% growth in monthly sign-ups:
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E-commerce solutions offered (shopping carts, credit card processors, resale agreements):
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# of Web Developers in your reseller base:
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Do you provide dial-up access?
. Yes  No
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Do you offer e-commerce hosting packages?
. Yes   No
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Can PaymentNet e-mail new programs/service enhancements/special offers to you?
. Yes   No
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Comments/Questions:
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