Date of Application

* MM/DD/YYYY

Company Information

Company Name:

*

Address 1:

*

Address 2:

City:

*

State:

*

Postal Code:

*

Country:

Telephone:

*

Fax:

Website:

*

Stock Symbol :

Exchange:

Partner Contact Information (The same person may fill more than one roll)

1.

Executive in Charge:

First Name:

*

Last Name:

*

Title:

*

Address:

leave blank if same as above

Phone:

*

Email:

*

2.

PIX Coordinator:

First Name:

*

Last Name:

*

Title:

*

Address:

leave blank if same as above

Phone:

*

Email:

*

3.

Marketing Contact:

First Name:

Last Name:

Title:

Address:

leave blank if same as above

Phone:

Email:

4.

Technical Contact:

First Name:

Last Name:

Title:

Address:

leave blank if same as above

Phone:

Email:

Main Product Category of Interest

Self-Service Terminals (SSTs, ATMs)

Express Delivery (and related products)

What areas of business does your company participate in?

Ancillary Products

Provides supplementary products such as simulators and configurators, etc.

Application Developers and Integrators

Provides ATM and integration software solutions, i.e. graphic integration, etc.

Consulting Services

Provides additional resources for writing software

Host Authorization Software

Provides processing software solutions that banks can buy

Network/Switch (National)

Provides a path to an authorizing host – National

Network/Switch (Regional)

Provides a path to an authorizing host – Regional

Processor

Offers verification and transaction approvals, or sends transaction to another network (banks may choose to outsource this service)

Telecommunications

Provides the means to transmit messages

Other Product and Service Providers

Offers server products, check cashing, ATM dispensing, gateway internet access, etc.

Other (Please Specify)