Merchant Name (DBA or Trade Name)
Corporate/ Legal Name
Location Address
Corporate/ Billing Address
City/State
Zip/Postal Code
Country
Contact Name / Relationship
Email Address
Technical Contact Name
Telephone Number
Fax Number
Billing Contact Name
Number of Years In Business
Company Registration Number / Federal Tax ID
Type of Business:
Sole ProprietorLimited Liability CompanyCorporationPartnership
Name - Principal #1
Title
% Owned
Date of Birth
Identification Type
State/County of ID
Address
City, State
Name - Principal #2
Please provide a profile of the company
Current Processor:
Current Gateway :
Reason for leaving current processor:
Length of time accepting credit cards:
Method of Acceptance (must equal 100%): MOTO: % Internet: % Swipe: %
Estimated Monthly Volume
Average Ticket
Highest Ticket
URL(s):
Desired Descriptor (25 character max): Ex: (company name, phone #, URL) will be shown on Credit Card statement
Description of products services sold
Continuity Billing?
YesNo
If yes describe:
Please answer the following questions:
1. Type of Product or Service Sold?
2. Is the product/service being sold as Business-to-Business, Business-to-Consumer or both?
3. Who is your current processor (if applicable)?
4. How long have you been processing with the current processor?
5. When is the customer charged for the purchase?
6. How long after the time of the order does the cardholder receive the product or service?
7. What is your refund/cancellation policy?
8. Website Address (URL):
Descriptor:
Support Phone Number:
*We will only request this document if needed
Articles of Incorporation
Copy of Valid State-Issued Drivers License for All Signers on the Account
Copy of a Voided Business Check
Most Recent 3-6 Months of Processing Statements
Most Recent 3 Months of Business Bank Statements
Proof of Domain Registration to Verify Ownership of the URL(s)
Most Recent Year's Corporate Tax Returns*
Most Recent Year's Profit & Loss*
Most Recent Year's Balance Sheet*
Omniqore Payments
Omniqore Payments