| Contact Information |
| Contact Name: |
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| Contact Phone: |
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| Contact Phone Extension: |
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| Street Address: |
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Which solutions do you require (please check all that apply)? |
Virtual Point of Sale
Online Payment Form
Custom Payment Application
Custom Reporting Interface
Data Conversion Utility
Batch Upload Utility
Recurring Payments Interface
Integration Assistance
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Please provide a short description of your requirements. |
Does this application replace an existing payment application or is it new?
New
Replaces |
Do you require a method of authenticating users for access to the application?
Yes
No |
Will your system(s) output data to be uploaded to the Skipjack system?
Yes
No |
Will your system(s) import transaction results data from the Skipjack system?
Yes
No |
How many users will access the application(s)? |
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Will you be hosting the payment application or do you want Skipjack to host? |
Is credit card swipe required to populate the application interface?
Yes
No |
Do you require specialized data entry rules on the application interface?
Yes
No |
Do you currently have a Skipjack Account?
Yes
No |
What is your target launch date?
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Payment Gateway 
