Merchant Pre-Application

(*) = required data

*Company Name or DBA:
*Merchant Website URL(s):
*Contact Name:
*Contact Email Address:
*Contact Phone Number:
Alternate Phone Number:
*Merchant Type:
*Describe in detail what services/products you sell:
*How do you sell your product / service? (indicate %):	Retail:
	Internet:
	Mail Order:
	Phone Order:
*Current / Projected Monthly Volume (USD):
*What is your Average Ticket Amount? (USD)
*Who is your Current Processor?
*What Banks / ISOs have you processed with before?
*Has your processing ever been terminated?	Yes	No
If Yes, what bank / processor terminated you and for what reason?
*Where else did you apply for a merchant account?
*What is your current Charge Back ratio?
*What discount rate are you seeking?
*Are you requesting a USA or Off Shore Solution?	USA	Off Shore
*What Country(s) is your company incorporated in?
*Do you offer an affiliate program?	Yes	No
*Do you outsource product fulfillment?	Yes	No
*Do you have 24/7 customer service?	Yes	No
*Do you need a re-curring billing solution?	Yes	No
*Do you need a shopping cart?	Yes	No
*Do you use inbound / outbound telemarketing?	Yes	No

comments or questions: