Millyard Service Referral Form Referrer Information Referrer Name* Referrer Branch/Dept* Referrer Email* Company Information Company* Business Owner’s Name* Street* City* State/Province* Zip* Website Industry* --None--Agriculture Apparel Banking Biotechnology Chemicals Communications Construction Consulting Education Electronics Energy Engineering Entertainment Environmental Finance Food & Beverage Government Healthcare Hospitality Insurance Machinery Manufacturing Media Not For Profit Other Recreation Retail Shipping Technology Telecommunications Transportation Utilities Existing Dep/Loan Customer?* --None--Yes No Current Merchant Provider Can Provide Current Merchant Statements? --None--Yes No Estimated Annual Credit Card Volume:* --None--Up to 100K 100 - 500K Over 500K Terminal Type Point of Sale Software Type Additional Notes Contact Information Contact Person's First Name * Contact Person's Last Name* Contact Person's Title* Phone* Email* * Indicates Required Field
