New Customer | Insight Retail Software

Store Name *

Store Owner Name *

First

Last

Store Owner Email Address *

Store Owner Phone *

Alternate / Mobile Phone Number

Store Physical Address (No PO Box) *

Address Line 1

Address Line 2

City

State

Zip Code

Technical Contact Name

First

Last

Technical Contact Email Address

Technical Contact Phone

Altria Account Number

Altria Account Rep

RJR Account Number

Current backOffice Provider (if applicable)

Who is your current credit card provider?

Are you currently offering cash discounts on credit card transactions?

If currently submitting scan data through 3rd party - please identify company

Referral Source

What did you search for?

Payment Information *

Billing Contact Name *

First

Last

Billing Contact Email Address *

Billing Contact Phone *

Billing Address Same as Store Address *

Additional Notes

Anything we should know, preferences, etc.

New Customer Form