Merchant Account Application

CONTACT DETAILS

Company Name
Contact Person*
Business Address 1*
Business Address 2*
City*
State*
Zip*
Country*
Country of Incorporation
Telephone
Fax
Email Address*
Website (If any)
BUSINESS INFORMATION
Type of Business*
Please give a detailed explanation of your business and services*
PROCESSING DETAILS
How long have you been in business?*
What is the average amount you process monthly in American dollars?*
Enter Average Amount Per Month*
Average Amount of Transactions Per Month*
Average Sale Amount ($)*
Monthly % of Chargebacks*
Do you require ACH/Echeck Processing Services?*
Have you ever had your own merchant account?*
Do you require a shopping cart?*
Are you going to be recurring billing (subscriptions)?*
Please explain below any kind of special requests or scripts that you require for your online store or membership site

Security Code: (note: all letters are lower case.)
By submitting this pre-application you understand that all information submitted will be kept strictly confidential and that you will also be required to submit an additional application on pre application approval for final approval.