High Risk Merchant account / Processing
This form will help us determine what type of merchant account is right for your needs.
Note:The information that you provide will be kept strictly confidential

Merchants selling non-high risk goods and services - Please use this form here...
Main business type:

Company Information
Doing Business As (DBA):
Description of
Product(s)/Service(s) Sold:
Address:
City:
State/Province:
Zip/Postal Code:
Country:
Phone:
Fax:
Account Executive
Primary Contact Name:
Primary Contact Title:
Primary Contact Email:
Primary Contact Telephone:
Primary Contact Telephone Extension:
Web Site Information
Web Site Name:
Web Site URL:
Administration Email:
Customer Service Phone #:
Put Customer Service Phone # on email receipts?:
Processing Information
Average Sale Price:
Monthly Volume:
Processing Currency:




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