Merchant Pre-Application & Quote Request


	Merchant Pre-Qualification Questionaire ** This is NOT the complete application - this is a pre-application - Additional information may be required for approval.

*Company Name:

Company name - legal registered name.

*DBA:

DBA name - Doing Business As

*Business Type:

Or:

*Company Street
Address:

Street or Mailing address is accepted.

*City:

City Name

*State (US Only):

State - US Only - If Non-US please leave blank - there will be an option for non-US below.

*Canadian Province
(CA Only):

Canadian Province - Non Canadian please leave blank.

*Zip - Postal Code:

Zip or Postal Code

*Province or District
(non-US or CA):

(chars left: 200)

Additional address and postal information for Non-US and Non-CA merchants.

*Website URL:

Enter your website url. Example: http://www.YourDomain.com


	Company Profile

*Date Business
Established:

(chars left: 15)

Enter the date that the company was established. DD/MM/YYYY

*Business Description:

(chars left: 250)

Business Description: Day to day operations and proceedures - main products or services.

*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...

*Customer Services:

(chars left: 250)

Describe how customer service responds when contacted for support.

*Refund & Cancellation Policy:

(chars left: 250)

Describe your Refund & Cancellation policy.

*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

*Estimated Monthly
Volume:

$

*Average Ticket /
Sale:

$	Average tickst - sale amount in USD.

*Highest Ticket:

$	Highest expected ticket / sale amount for a single sale.

*Bankruptcy:

YES

NO

Has the applicant or owner of this business ever filed for bankruptcy ?

*Terminater Merchant:

YES

NO

Has the owner or applicant ever been terminated or currently on the match list ?

*Processing History:

YES

NO

Does the owner or applicant have current or previous processing history ?

*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.

*Reason for Applying:

(chars left: 100)

What is the reason that you are applying for a merchant account ?


	Contact Information

*Title:

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.

*Email:

Enter up to 3 email addresses.

*Image Verification:

Enter the code above.


	M-E-R-C-H-A-N-T.com \| Alltech Distributors LLC \| 7245 S. 76th Street \| Franklin WI 53132-9041 \| Toll Free US & Canada 1-888-884-2447 \| International * +1-312-235-2211