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PRE-APPLICATION MERCHANT FORM
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Registration
PRE-APPLICATION MERCHANT FORM
Type of Payment Method:
Credit Cards
Credit Cards & ACH
ACH Low Risk
ACH High Risk
POS Retail
Type of Account Required:
International Account
American Account
Canadian Account
European Account
Name Of Business:
*
Contact Name:
*
Contact Email:
*
Business Address:
*
Country:
Afghanistan
Albania
Alderney (ch. Islands)
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Australia and New Zealand
Austria
Azerbaidjan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia-Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei Darussalam
Bulgaria
Burkina Faso
Burma
Burundi
Cambodia
Cameroon
Canada
Canada
Cape Verde
Cape Verde and Canary Islands
Carribbean - other US
Cayman Islands
Central African Republic
Central America
Central Asia
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo, Dem. Republic (Zaire,Kinshasa)
Congo, Republic of (Brazzaville)
Cook Islands
Costa Rica
Cote D'Ivoire (Ivory Coast)
Croat. Serb. Bosn. Maced. Sloven.
Croatia
Cuba
Cyprus
Czech Republic
Czechoslavakia - select Czech or Slovak republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
England
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Far Southern Islands
Faroe Islands
Fiji
Finland
France
France (European Territory)
French Guyana
French Southern Territories
Gabon
Gambia
Georgia, Republic of
Germany
Ghana
Gibraltar
Great Britain
Great Britain, Ireland, Ch. Isles
Greece
Greenland
Grenada
Guadeloupe (French)
Guam (USA)
Guatemala
Guernsey (ch. Islands)
Guinea
Guinea Bissau
Guyana
Haiti
Heard and McDonald Islands
Holland
Holy See (Vatican City)
Honduras
Hong Kong
Hungary
Iceland
Iceland and Greenland
India
Indonesia
Indonesia and other Islands
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Ivory Coast (Cote D'Ivoire)
Jamaica
Japan
Japan, S.Korea, Taiwan, Phillipines
Jersey (ch. Islands)
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyz Republic (Kyrgyzstan)
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique (French)
Mauritania
Mauritius
Mayotte
Mexico
Mexico
Micronesia
Middle East including Egypt
Moldavia
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
Neutral Zone
New Caledonia (French)
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Ireland
Northern Mariana Islands
Norway
Oman
Other Carribbean and West Atlantic
Pacific - other Islands
Pacific US Possessions
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Island
Poland
Polynesia (French)
Portugal
Puerto Rico
Puerto Rico
Qatar
Republic of the Congo
Rest of East Asia
Rest of Europe
Rest of North and West Africa
Rest of Western Europe
Reunion (French)
Romania
Russian Federation
Russian Federation
Rwanda
S. Georgia & S. Sandwich Islands
Saint Helena
Saint Kitts & Nevis Anguilla
Saint Lucia
Saint Pierre and Miquelon
Saint Tome and Principe
Saint Vincent & Grenadines
Samoa - select Western or American
San Marino
Sark (ch. Islands)
Saudi Arabia
Scandanavia
Scotland
Senegal
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovenia
Solomon Islands
Somalia
South Africa
South America
South Asia and Indian Ocean
South Korea
Southern Africa and Mozambique
Southest Asia
Southwest Asia
Spain
Sri Lanka
state of Hawaii
Sudan
Suriname
Svalbard and Jan Mayen Island
Swaziland
Sweden
Switzerland
Syria
Tadjikistan
Taiwan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States
Uruguay
US or British
US Virgin Islands
USA Minor Outlying Islands
Uzbekistan
Vanuatu
Vatican City State
Venezuela
Vietnam
Wales
Wallis and Futuna Islands
Western Sahara
Western Samoa
Yemen
Zaire - Congo, Dem. Republic
Zambia
Zimbabwe
State / Province:
*
ZIP / Postal Code:
*
Daytime Phone:
*
Business Fax:
Legal Business Name:
*
Principal Owner:
*
Type of Product:
*
Age of Business:
*
(years)
Current Processor:
*
Monthly Card Volume:
*
Average Sales Ticket:
*
Website URL:
*
Monthly Cargebacks:
Credit Card Accept:
Visa & Master Card
Master Card
Visa Card
Amex
Discover
ECHECK
ACH
None
3rd Party Account:
Direct Merchant Account
3rd Party Merchant Account
Comment:
*
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