REQUESTED SERVICES/INTERESTS
(check all that apply)

 U.S. Merchant Account European Merchant Account International Merchant Account ACH/eCheck Processing Mobile Payments Prepaid Debit Cards Fraud & Dispute Alerts European Incorporation International Business Company (IBC) Belize Incorporation Corporate Settlement Bank Account *International Website Hosting

CONTACT INFORMATION

*Name

*Email

*Confirm Email

*Phone

Second Phone

BUSINESS INFORMATION

Website Address(es)

Customer Service Phone

Type of Merchant (check all that apply)
 Products - Ship Tangible Goods Service Provider (Online) Digital Goods - Downloadable Physical Storefront

Type of Transactions (check all that apply)
 API Integrated Gateway - Customer Enters Credit Card Data on Website Mail & Telephone Order - Merchant Enters Credit Card Data on Virtual Terminal Subscription Based Service - Recurring Billing Point of Sale - Card Present Transactions

Length of Time Processing Transactions

Current Processor(s)

If Ever Terminated, Processor that Filed Termination

Total Monthly Volume

Monthly Volume Needed

Average Transaction Amount

High Transaction Amount

Currencies Needed

Detailed Description of Products/Services Offered, All Pricing for Such, How Long Fulfillment Takes, and How Customer Service is Carried Out

COMPANY INFORMATION

Legal Business Name

DBA Name

Company Address

Company City

Company Province/State

Company Zip Code

Company Country

Incorporation Number

Federal Tax ID (if U.S. company)

Primary Owner's Name

Owner Resident Address

Owner City

Owner Province/State

Owner Zip Code

Owner Country

Email

Phone

SSN (if applying for U.S. merchant account)

Message