** Type of Payment Method:
** Type of Account required:
Name of Business:
*
Contact Name:
*
Contact Email:
*
Business Address:
*
State/Province
:
*
Zip/Postal Code:
*
Daytime Phone:
*
Business Fax:
*
Legal Name of Business:
*
Principal Owner:
*
Type of Product or Service Sold:
*
Age of Business:
*
** What credit cards do you currently accept ?:
Who is your current processor:
*
Indicate Monthly Visa and MasterCard volume:
*
What is your average sales ticket:
*
What is your website url:
*
Which country are you incoporated in?:
*
What percent is your monthly chargebacks?:
*
** Direct or 3rd Party Account (new business):
Comments:
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