Merchant Pre-Application & Quote Request
*
- required
Merchant Pre-Qualification Questionaire
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Company Name:
Company name - legal registered name.
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DBA:
DBA name - Doing Business As
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Business Type:
Retail Swipe
Ecommerce Website
Travel
Membership
Recurring Billing
Digital Downloads
MLM
Shopping Club
Medical
Legal Services
Pharmacy
Biz Opps
Collections
Loan Modification
Online Advertising
Timeshare Sales
Realestate Broker
Limo Service
Sports Predictions
Timeshare Ads
High Volume
Furniture
Pay Day Loans
Clothing
Adult Products
Adult Services
Lottery Tickets
Property Rental
SEO Services
Web Design
Hosting Provider
Domain Registrar
Other
Or:
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Company Street
Address:
Street or Mailing address is accepted.
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City:
City Name
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State (US Only):
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State - US Only - If Non-US please leave blank - there will be an option for non-US below.
*
Canadian Province
(CA Only):
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Canadian Province - Non Canadian please leave blank.
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Zip - Postal Code:
Zip or Postal Code
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Province or District
(non-US or CA):
(chars left:
200
)
Additional address and postal information for Non-US and Non-CA merchants.
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Website URL:
Enter your website url. Example: http://www.YourDomain.com
Company Profile
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Date Business
Established:
(chars left:
15
)
Enter the date that the company was established. DD/MM/YYYY
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Business Description:
(chars left:
250
)
Business Description: Day to day operations and proceedures - main products or services.
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Marketing and
Promotions:
(chars left:
250
)
Describe the marketing and promotional methods used to advertise this business - I.E. newpaper, yello pages, incound telemarketing ect...
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Customer Services:
(chars left:
250
)
Describe how customer service responds when contacted for support.
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Refund & Cancellation Policy:
(chars left:
250
)
Describe your Refund & Cancellation policy.
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Delivery & Shipping Methods:
(chars left:
250
)
Delivery & shipping methods - Example: Digital downloads after payment received.
UPS and FEDEX with delivery confirmation - shipped within 24 hours signature required.
Risk Assessment
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Estimated Monthly
Volume:
$
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Average Ticket /
Sale:
$
Average tickst - sale amount in USD.
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Highest Ticket:
$
Highest expected ticket / sale amount for a single sale.
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Bankruptcy:
YES
NO
Has the applicant or owner of this business ever filed for bankruptcy ?
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Terminater Merchant:
YES
NO
Has the owner or applicant ever been terminated or currently on the match list ?
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Processing History:
YES
NO
Does the owner or applicant have current or previous processing history ?
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Payment Options:
(chars left:
100
)
Please list all payment methods currently used. Example: Checks, Cash, ACH, ect...
*
Customer Origin:
(chars left:
100
)
List the major countries of origin that your customers order from.
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Reason for Applying:
(chars left:
100
)
What is the reason that you are applying for a merchant account ?
Contact Information
*
Title:
Mr.
Mrs.
MS
Dr
CEO
CFO
CTO
Owner
President
Other
Or:
*
First Name:
First Name
*
Last Name:
Last Name
*
Telephone:
-
-
x
Owner / Manager telephone number.
Fax Number
(optional):
-
-
Fax Number
*
Cellular / Mobile
Phone:
Cellular / Mobile phone number.
International
Telephone:
International telephone number - please include the country code.
*
Birth Date:
(chars left:
15
)
Date of Birth - DD/MM/YYYY
*
Email:
Enter up to 3 email addresses.
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