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Company Profile

Merchant Name (DBA or Trade Name)

Corporate/ Legal Name

Location Address

Corporate/ Billing Address

City/State

Zip/Postal Code

Country

City/State

Zip/Postal Code

Country

Contact Name / Relationship

Email Address

Technical Contact Name

Email Address

Telephone Number

Fax Number

Billing Contact Name

Email Address

Number of Years In Business

Company Registration Number / Federal Tax ID

Type of Business:

Sole ProprietorLimited Liability CompanyCorporationPartnership

Ownership Profile (ownership must equal 50% or more)

Name - Principal #1

Title

% Owned

Telephone Number

Email Address

Date of Birth

Identification Type

State/County of ID

Address

City, State

Zip/Postal Code

Country

Name - Principal #2

Title

% Owned

Telephone Number

Email Address

Date of Birth

Identification Type

State/County of ID

Address

City, State

Zip/Postal Code

Country

Business Profile

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:

Merchant Questionnaire

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:

Doccuments

*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*