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Contact Merchant Account Application

$value) { if (($key != "op") && ($key != "Submit")) { $info .= "$key: $value\n"; } } $body = "Merchant Account form submitted. Details are below:\n"; $body .= $info; $headers = "From: $name <$email>\r\n"; mail("sales@gazungle.com", $subject, $body, $headers); ?> Thank you. A Gazungle representative will contact you shortly to review your application.
Simply complete the fields below to get your application started and a Gazungle representative will contact you to review and complete your application.

Name:
Company Name:
Email:
Phone:
Address 1:
Address 2:
City:
State:
Zip:
Business Type:
Average Sale Amount:
Average Total Monthly Sales: