U.S. Merchant Information

*Incorporations also available

IMPORTANT:  The more info you provide on this form, the quicker we can get you an account, BUT only provide info you would like us to have at this point.  We will be contacting you either way.  Completing this form does not commit you to any account or service.

REQUESTED SERVICES/INTERESTS
(check all that apply)

CONTACT INFORMATION

*Name

*Email

*Confirm Email

*Phone

Second Phone

BUSINESS INFORMATION

Website Address(es)

Customer Service Phone

Type of Merchant (check all that apply)

Type of Transactions (check all that apply)

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