YOUR HIGH PRESENCE, HIGH TRAFFIC PROVIDER

Pre-Qualification Credit Card Payments Request

Reminder: Please fill out this form if you are currenctly seeking a merchant account. Please provide maximum details.

Personal Information

Title:
Mr. Ms. Mrs.

Full Name: (*)

E-mail address: (*)

Alternative Email address:

Company Designation:

Nationality:

Phone No.: (*)

Correspondence Address:

Yahoo Messenger ID :

MSN Messenger ID :

How do you know us?:

Company Information

Legal/Corporate Name:: (*)

Year Established: (*)

Company e-mail address: (*)

Alternative Email address:

Phone Nos. :

Fax No.: (*)

Business Complete Address:

Does your company has an existing
EU company registration?:

If no, are you willing to have an EU company?:

Business Model

Merchant Website (to be used in credit card acceptance) :

Website Industry :

Please describe your business model :

Does your company presently or in the past, accept credit card for processing? :
if yes please fill up the processing history

What is your Expected Monthly Volume Amount:
if no,

Expected Monthly Transaction :

Payment Processing History and Information / Payment and Risk Management

Transaction Currencies :

Monthly Volume Amount :

Monthly Transaction Amount :

Former Processor :

Reasons for leaving :

Other payment methods used? :

Notice: This form will assist your merchant services representative in setting up your merchant account.
Please fill out this form completely and click the submit button.

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Credit Card Payment Processing