STEP 1
STEP 1
STEP 2
STEP 2
STEP 3
STEP 3
STEP 4
STEP 4
FINAL STEP
FINAL STEP
Referral Agent's DBA Name
Referral Agent's DBA Name
LEGAL BUSINESS INFORMATION
Legal Entity Name
Legal Entity Address
Legal Entity Zip Code
Legal Entity City
Legal Entity State
Legal Entity Country
Legal Entity Phone
Type of Ownership
State of Formation
Fed Tax ID Type
FEIN or Social Security Number
Year Business Established
Years in Business
Years Business Owned by the Current Owner
Any Prior Bankruptcy
Type of Bankruptcy
Bankruptcy Date
PRIMARY CONTACT INFORMATION
Contact Full Name
Contact Email
Contact Phone
Contact Mobile
BUSINESS CONTACT INFORMATION
Business Contact Full Name
Business Contact Email
Business Contact Phone
Business Contact Mobile
Customer Service Phone
Does your business have a website
Primary Website Address
TECHNICAL CONTACT INFORMATION
Technical Contact Full Name
Technical Contact Email
Technical Contact Phone
FUNDS SETTLEMENT BANK INFORMATION
Bank Name
Bank Contact Name
Bank Phone
ABA Rounting Number
Bank Account/DDA Number
Industry Type
If not listed above, please fill in the industry type here
GOODS & SERVICES
Type of Goods/Services
Describe the Goods/Services Provided
Percentage Provided by Internet
Percentage Provided by Mail Order
Percentage Provided by Phone
Goods/Services Delivery Period
If Other, please describe further
Average Days for Delivery
Bought goods from a vendor
Vendor Address
Refund Policy
If Other, please describe further
Do you charge a Restocking Fee?
Is a deposit required on any sales?
Deposit Percentage
MARKETING METHODS
If Other Marketing please describe further
Do you use product Fullfillment Services?
Do you have any processing history?
PRODUCT FULFILLMENT
Fullfillment Method
If you chose Other above please describe further
Fulfillment Vendor Name
Fullfillment Vendor Address
Fullfillment Vendor Zip
Fullfillment Vendor City
Fullfillment Vendor State
Fulfillment Vendor Phone
Fulfillment Vendor Contact
Do you use a shopping cart
Shopping Cart Name
PROCESSING SUMMARY & HISTORY
Annual Processing Volume
Max Monthly Processing Volume
Average Monthly Processing Volume
Max Ticket Size
Average Ticket Size
Do you accept bank cards now
What percentage of your transactions are international cards
Have you ever had a merchant account terminated
If yes please explain
Who is your current processor
If you no longer use a processor what is your reason for leaving
Current Gateway Vendor Name
Which email would you like the charge back notifications sent to
Do you process seasonal sales
Peak months for seasonal sales
Peak dollar volume for seasonal sales
Do you process recurring transactions
If Other please explain further
Percentage of Monthly Recurring Transactions
Percentage of Annual Recurring Transactions
Percentage of One Time Transactions
Percentage of Other Frequency Transactions
PCI-DDS COMPLIANCE
Do you store credit card data
Any data breaches?
Are you PCI compliant?
If no, please explain.
PCI Compliance Date
How do you secure your data?
Do you use a website host provider?
Who is your host provider?
PRINCIPAL #1 INFORMATION
Principal First Name
Principal Last Name
Principal Title
Principal Percentage of Ownership
Principal Home Address
Principal Zip Code
Principal City
Principal State
Does the Principal own or rent a home?
Years Principal lived at current home?
Principal Home Phone
Principal Mobile Phone
Principal Email
Principal Country of Citizenship
Principal Social Security Number
Principal Date of Birth
Government Issued ID Type
Government Issued ID Number
Government Issued ID State
Governement Issued ID Expiration Date
Name of Relative not living with you
Phone Number of Relative Not Living with you
LEGAL BUSINESS INFORMATION
Principal #2 First Name
Principal #2 Last Name
Principal #2 Title
Principal #2 Percentage of Ownership
Principal #2 Home Address
Principal #2 Zip Code
Principal #2 City
Principal #2 State
Does Principal #2 own or rent a home?
Years Principal #2 lived at current home?
Principal #2 Home Phone
Principal #2 Mobile Phone
Principal #2 Email
Principal #2 Country of Citizenship
Principal #2 Social Security Number
Principal #2 Date of Birth
Principal #2 Government Issued ID Type
Principal #2 Government Issued ID Number
Principal #2 Government Issued ID State
Principal #2 Government Issued ID Expiration
Name of Relative not living with you
Phone Number of Relative Not Living with you
BUSINESS LOCATION INFORMATION
Type of Zoning for your business
Type of Premises
If Other, please describe further
Square Footage of the Location
Premises Ownership
If Other, please describe further
Multiple Business Locations
Number of Locations
PLEASE UPLOAD FOLLOWING DOCUMENTS
Certificate of Incorporation
Max. size: 256.0 MB
Tax ID document/ SS4
Max. size: 256.0 MB
Owner's driver's license
Max. size: 256.0 MB
Void check for each of the bank accounts where deposits can be made (please do include the month and year when the account was opened)
Max. size: 256.0 MB