Merchant Pre-Check Form

MERCHANT PRE-CHECK FORM
SECTION 1: BUSINESS INFORMATION
Legal Business Name*
DBA (Doing Business As)
Business Type*

CorporationLLCSole PropOther
Business Start Date*

MonthDayYear
Date
Business Website
Business Phone Number
Please enter a valid phone number.
Business Email*
example@example.com
Physical Business Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Business Category (MCC or description of goods/services)*
SECTION 2: OWNERSHIP DETAILS
Owner/Manager Full Name*

First NameLast Name
Ownership Percentage
Owner Date of Birth

MonthDayYear
Date
Owner SSN or ITIN
Owner Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner Email*
example@example.com
Owner Phone Number
Please enter a valid phone number.
SECTION 3: PROCESSING HISTORY
Applying Website
Do you have a members area?

YesNo
Test Username
Test Password
Are you currently processing payments?*

YesNo
If yes, Current Processor Name?
Processing Since (date)

MonthDayYear
Date
Current Monthly Processing Volume*
Average Ticket Size*
Highest Ticket Size*
Have you ever had a merchant account terminated?*

YesNo
If yes, explain reason
SECTION 4: FINANCIAL & BANKING
Monthly Revenue (Gross)*
Anticipated Monthly Credit Card Volume*
Bank Name
Bank Account Type

BusinessPersonal
Routing Number
Account Number
SECTION 5: PRODUCT FULFILLMENT & CHARGEBACKS
How are the products/services delivered*

PhysicalDigitalIn-Person
Fulfillment timeframe*
Do you offer recurring billing/subscriptions?*

YesNo
Chargeback ratio (last 6 months)*
Refund ratio (last 6 months)*
SECTION 6: RISK INDICATORS
Do you use affiliate marketing?

YesNo
Do you sell internationally?

YesNo
Is your business regulated (FDA, FTC, etc.)?*

YesNo
If yes, provide details
Additional Comments or Notes
SECTION 7: DOCUMENTS TO ATTACH
Government-Issued ID (Owner)

Cancelof
Voided Check or Bank Letter

Cancelof
3-6 Months of Processing Statements

Cancelof
Business License or Legal Opinion (if applicable)

Cancelof
Fulfillment Agreement (if available)

Cancelof
Signature

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MERCHANT PRE-CHECK FORM

SECTION 1: BUSINESS INFORMATION

SECTION 2: OWNERSHIP DETAILS

SECTION 3: PROCESSING HISTORY

SECTION 4: FINANCIAL & BANKING

SECTION 5: PRODUCT FULFILLMENT & CHARGEBACKS

SECTION 6: RISK INDICATORS

SECTION 7: DOCUMENTS TO ATTACH