New Agent Application

Business Name___________________________________________________________________________________

DBA Name (if different)___________________________________________________________________________

Contact Name___________________________________________SS#(Required)_____________________________

Address_________________________________________________________________________________________

City/State/Zip_____________________________________________________________________________________

Home Phone____________________________________ Work Phone______________________________________

Fax______________________________________Email__________________________________________________

Description of Products and Services_________________________________________________________________
.
________________________________________________________________________________________________
.
________________________________________________________________________________________________

Type of Business (be specific)_______________________________________________________________________
.
Average Transaction_________________________Estimated Monthly Volume________________________________

Mailing Information:
For Visa & MasterCard Processing, please mail or fax* this application, with the agreement and a check to:

                    TeleCharge Texas - 019
                    450 N. Sam Houston Park Way, Suite 273
                    Houston, TX  77060
                    Attention: TeleCharge Agent Service - Chuck Taylor Sr. Account Rep.
                    Fax:   281-445-7257
*The original copy must follow all faxed information.

Please call 800-948-6457 for all customer service questions. We look forward to servicing your business; and thank you for choosing TeleCharge the simple access to credit card processing!

TeleCharge, Inc.
Application
1/13/98 ..

    
.
......