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DBA (if applicable):
Company Zip/Postal Code:
Company Email Address:
Country/State of Registration:
EIN/VAT/Tax ID/File Number:
% of Ownership:
Date of Birth:
Passport/ Driver ID#:
Country of Nationality:
$ Number of transactions/month:
Minimum ticket amount $:
Maximum ticket amount $:
Average ticket amount $:
Reason for applying:
If you are not a startup business but, there is no processing history, please explain. (if applicable):
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
Have you ever had merchant account terminated: yesno
If yes, please state the reason:
Time with Processor:
Bank Information (Should be Under the Company Name)
Account Holder Name:
Account Holder Address:
Account Holder Country:
Bank Routing Number:
Bank Account Number:
Combined Estimated Monthly Volume $:
Est. Monthly Volume (Amex) $:
Typical Ticket/ Sales Amount $:
Estimated Highest Ticket/Sales Amount $:
Provide a detailed description of your business?:
In which currency are your products sold?:
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 ?