Merchant Application - www.High-Risk-Merchant.com
* - required
NEW MERCHANT REGISTRATION - Pre-Application
Company legal name or registered name.
Company Address - Physical Address or main office.
City
State - If US Only
Canadian Provine - Canadian Only.
Province or District - For all Non-US or Non-Canadian Merchants.
Postal or Zip Code.
URL of Website: http://www.YourDomain.com
COMPANY PROFILE
/ / Date Chooser
Date the business was started / Registered.
(chars left: 200)
Business Description: Day to day operations and proceedures - main products or services.
(chars left: 200)
Describe the marketing and promotional methods used to advertise this business - a.e. newspaper, inbound telemarketing, yellow pages, ect...
(chars left: 200)
Describe how customer service works when contacted for help or support.
(chars left: 200)
Describe merchants Refund & Cancellation Policy.
(chars left: 200)
Delivery or Shippong Methods - Example: Digital Downloads after payment received. - or - UPS and FEDEX with delivery confirmation - shipped within 24 hours.......
RISK ASSESSMENT PROFILE
Is this business membership based ?
Has the Business or Owner ever filed for Bankruptcy ?
Has the Applicant or Business ever been terminated?
Does the applicant have previous or current processing history for this business ?
Specify all other options of payment accepted other than credit cards accepted by applicant.
List major countries that merchants customers come from.
What is the reason you are applying for this merchant account ?
OWNER - MANAGER INFORMATION
First Name
Last Name
- - x
Owner / Manager Telephone Number
- -
Fax Number to send contract or documents for signature.
Cell phone or mobile phone number.
International phone number can be entered here.
Title of Applicant
Date of birth format: DOB (YYYY-MM-DD)
Enter multiple email addresses on separate lines. ** Include applicant listed here and up to 3 other contact emails on separate lines.
Name of referring ISO or Agent
Form Generated by Techform - Alltech Distributors LLC, Milwaukee, Wisconsin