MERCHANT APPLICATION FORM
Merchant Industry:
CREDIT CARD ACCOUNT TYPE: ECOMMERCE MOTO 3D Secure/VbV(Requested)
Merchant Name
DBA (If Applicable):
Primary/Trading Details
Registered Address:
Postal Code and City:
Country:
Other Location
Address:
City / Town:
State / Province/ ZIP:
Country:
Main Company Phone/Email
Primary Contact Name:
Primary Contact Email/Phone:
BENEFICIAL OWNER INFORMATION If more than one Beneficial Owner/Director, please attach additional pages(s)
Owner’s Name:
Title and Ownership %: DOB:
Home Street Address:
City / Town:
State / Province Zip / Postal
Code:
Country:
Primary Telephone Number: Cell Phone:
Passport or Social Sec Number: Email:
Owner’s Name:
Title and Ownership %: DOB:
Home Street Address:
City / Town:
State / Province Zip / Postal
Code:
Country:
Primary Telephone Number: Cell Phone:
Passport or Social Sec Number: Email:
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MERCHANT APPLICATION FORM
COMPANY CONTACT INFORMATION
Financial Contact Name:
Telephone Number:
Email Address:
Fax Number:
Technical Contact Name:
Telephone Number:
Email Address:
Fax Number:
Customer Service Contact Name:
Hours of Operation/Time Zone:
Customer Svc Email:
Customer Svc Phone Number:
CURRENT PROCESSING
Are you processing now or have you ever processed credit card Yes No
transactions before?
Will your existing Merchant Account(s) remain open? Yes No
Have you ever had a Processing relationship terminated? Yes No
(If Yes, please explain in detail on a separate attachment)
How long have you been in business?
______Years ______Months
Name of Current Processor(s)
Reason applying for this
account
Projected Monthly Processing Volume – 1st Month US$:
Projected Monthly Processing Volume – 2nd Month US$:
Projected Monthly Processing Volume - 3rd Month US$:
AVERAGE Ticket size US$
MINIMUM Ticket size US$
MAXIMUM Ticket size US$
Desired Processing Currencies: USD EUR GBP Other – List:
Desired Settlement Currencies: USD EUR GBP Other – List:
PROCESSING DETAILS (Must Equal 100% for Each Section)
Asia Pacific ______% EU ______%
Caribbean & Latin America ______% Canada ______%
Central & Eastern Europe (non EU) ______% USA ______%
Internet /SSL ______% Telephone Order ______%
Consumer Cards ______% Commercial Cards ______%
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MERCHANT APPLICATION FORM
PRODUCTS / SERVICES INFORMATION
Please provide a detailed description of the goods and/or services you offer. Specifically, what is the
cardholder paying for and what do they receive?
Is the Product/Service fulfilled at the time of the sale? Yes No
If No, please state turn-around time from Order to Dispatch
Does your company fulfill orders directly? Yes No
If No, provide fulfillment company information details below:
Company Name:
Address:
Contact Name: Phone:
WEBSITE CONTENT (Check as appropriate)
Does the website(s) have pop-ups? Cross-promotions? Yes No
PLEASE LIST ALL URL’S (If necessary, attach a separate page)
LOGIN – You MUST provide a non-expiring “User ID” and “Password” for your website(s)
User ID:
Password:
Please specify the payment model (recurring,
one-time payment, pay per minute, etc)
How do you prove shipment (if applicable)?
Do you operate any affiliate programs? Are
they involved in the processing through this
account?
What will the cardholder be paying for through
your website?
Do you use other payment methods other than
credit cards? Please specify:
When is the cardholder charged for purchase
(when placing order, when shipped, etc)?
Do you send an email receipt to the cardholder
when the product/service fulfilled? If yes, please
include samples.
Do you distribute any materials and/or
agreements to customers; related to the services
offered? If yes, please include samples.
Rev 2012vB Page 3 of 4
MERCHANT APPLICATION FORM
MEMBERSHIP OR SUBSCRIPTION BASED PRODUCTS / SERVICES – Recurring Fees
Introductory trial for _______days: $
Recurring every ________days: $
Other: $
What does the cardholder receive with the Free or Introductory Trial?
SETTLEMENT BANK ACCOUNT INFORMATION
Owner of Account:
Bank Name:
Bank Contact Person:
Bank Telephone/Fax:
Bank Sort Code / IBAN:
SWIFT / Routing Number:
Account Number:
Account Currency:
SPECIFIC REPRESENTATIONS AND WARRANTIES
You represent and warrant at the time of this document and during the Term of this Agreement the following:
You are not engaged in or affiliated with any business, products or methods of selling other than those listed on this Application.
No owner with voting control of the Company, or with more than 5% of the shares, nor any signer of this Application has been
charged, arrested or convicted within the last five years of any criminal activity.
This Agreement violates no law, nor is it in conflict with any other agreement to which you are subject.
There is no action, litigation or proceeding pending or to your knowledge threatened which, if decided adversely would impact
your ability to carry on your business substantially as now conducted or which would adversely affect your financial condition or
operations.
You have never entered into an agreement with a third party to perform credit or debit card processing services, which have
been terminated by that third party, other than as identified in the Application.
You have never entered into an agreement with a processor, bank or gateway to perform credit or debit card processing
services, which have been terminated by that processor, bank or gateway, other than as identified in the Application.
All intended transactions are bona fide. No transactions involve the use of the card for any purpose other than the purchase of
goods or services from you.
You have provided all information accurately and without omissions or misleading statements and you have not withheld any
information that, if known to recipient, would influence recipient’s decision to enter into this Agreement.
IMPORTANT NOTICE BEFORE SIGNING THIS APPLICATION
The signer hereby authorizes the recipient to verify any information provided herein by the Applicant in response to the questions contained
in this Application and all exhibits and supporting documents provided. Recipient is authorized to use personal information provided to
obtain credit reports from authorized credit reporting agencies. Investigations, consumer credit reports and reference checking, or other
reasonable and legal means of investigation, may require verification by third parties to confirm information provided by Applicant and
Applicant hereby authorizes the recipient to undertake such verifications without further notice to the Applicant. The results of such
investigation remain the sole property of the recipient.
Application attested by (Authorized Signer) X______________________________________________________________________________________
Applicant’s Printed Name ______________________________________________________________________________________________________
Authorized Signer’s Title ______________________________________________________ Date ___________________________________________
Rev 2012vB Page 4 of 4
