Agent Name (if applicable):
Agent Email Address:
Agent Phone Number:
Agent Fax Number:
Company Name (Legal):
Doing Business As:
Contact Name:
Company Address:
City:
State:
Country:
Phone Number:
Cell Number:
Fax Number:
Website Address:
E-mail Address
Please provide password if site is under construction or password protected:
Business Type:
Description of Product/Services:
Country of incorporation:
Years of incorporation:
Estimated Monthly Volume:
Average Ticket:
Highest Ticket:
Have you ever processed credit cards before?
Yes
No
If you answered "Yes" above please indicate your current processor:
Reasons for requesting this account?
TMF (violation of merchant agreement or outstanding balance)
Low Credit Score (less than 500)
High Chargebacks (include monthly %
)
Capped Volume
New Business
How do you process or plan to process credit cards?
Are you interested in:
Retail
Wireless
Moto
Manually Swiped
Internet
Other (please specify
)
ACH
Check Programs
Additional Comments?