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Company Information

Company Name:

DBA (if applicable):

Company Address:

Company City/Town:

Company State/Province:

Company Zip/Postal Code:

Company Phone:

Company Email Address:

Country/State of Registration:

Incorporation Date:

EIN/VAT/Tax ID/File Number:

Ownership Information (Principal #1)

Full Name:

Home Address:

City/Town:

State:

Zip Code:

% of Ownership:

Cell Phone:

Alternate Phone:

Email Address:

Date of Birth:

Passport/ Driver ID#:

SSN/EIN:

Country of Nationality:

Ownership Information (Principal #2) (If Applicable)

Full Name:

Home Address:

City/Town:

State:

Zip Code:

% of Ownership:

Cell Phone:

Alternate Phone:

Email Address:

Date of Birth:

Passport/ Driver ID#:

SSN/EIN:

Country of Nationality:

Website Information

Website URL:

Products/Services:

Desired Descriptor:

Customer Service Contact

Contact Name:

Phone Number:

Contact Email:

Technical Contact

Contact Name:

Phone Number:

Contact Email:

Reference #1 (Any Company Your Firm Does Business With – Not Your Customers.)

Company Name:

Address:

Contact Name:

Phone Number:

Contact Email:

Reference #2 (Any Company Your Firm Does Business With – Not Your Customers.)

Company Name:

Address:

Contact Name:

Phone Number:

Contact Email:

Transaction Information

Estimated total:

sales/month:

$ Number of transactions/month:

Minimum ticket amount $:

Maximum ticket amount $:

Average ticket amount $:

Currencies requested:

Reason for applying:

If you are not a startup business but, there is no processing history, please explain. (if applicable):

Processing History

Do you currently accept credit cards?: yesno

Do you currently accept echecks or ACH payments?: yesno

Have you ever processed payments before?: yesno

Payment types you are applying to accept: VisaMC

ACH/echeck: DinersClubAmexCUPJCB

Have you ever had merchant account terminated: yesno

If yes, please state the reason:

Former/Current Processor:

Time with Processor:

Chargeback percentage ?

Bank Information (Should be Under the Company Name)
Account Holder Name:

Account Holder Address:

Account Holder Country:

Bank Name:

Bank Address:

Bank Country:

Bank SWIFT:

Bank Routing Number:

Bank Account Number:

Additional Information:

Estimated Monthly Volume & AVT Account Type

Combined Estimated Monthly Volume $:

Est. Monthly Volume (Amex) $:

Typical Ticket/ Sales Amount $:

Estimated Highest Ticket/Sales Amount $:

Business Description

Provide a detailed description of your business?:

In which currency are your products sold?:

Gateway Info

Do you have an existing gateway? yesno

IF yes Gateway name:

Do you want to take recurring payments? yesno

Do want to use a shopping cart to process transactions?: yesno

Types of Goods / Services you sell ?


Please specify the payment model (recurring, one-time payment, pay per minute, etc):


How do you prove shipment (if applicable)? Do you operate any affiliate programs? Are they involved in the processing through this account?


What will the cardholder be paying for through your website?Do you use other payment methods other than credit cards? Please specify:


When is the cardholder charged for purchase (when placing order, when shipped, etc)?


Do you send an email receipt to the cardholder when the product/service fulfilled? If yes, please include samples.


Do you distribute any materials and/or agreements to customers; related to the services offered? If yes, please include samples.


How do you get sales ?