High Risk Merchant Account Information
Enter your business information in order for us to match you to the best solution for your business.
BUSINESS NAME
*
CONTACT NAME
*
EMAIL
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Website
Business type. What do you sell?
*
Time in business?
*
Please Select
Less than 1 year
1 - 2 years
3 - 5 years
5+ years
If selling a physical product what is the fullfillment method?
*
Please Select
Own inventory in warehouse or office
Hold inventory in third party location
Fullfills form overseas supplier or manufacturer
Not selling a physical product
If Digital Product
*
Please Select
Where is your product hosted?
How is the product delivered?
Not a digital product.
If a Service
*
Please Select
Do you have a service provider agreement?
What is your fullfillment timeline?
Not a service.
What countries are your customers located in?
*
Are you a US citizen?
*
Please Select
Yes
No
Are you currently processing?
*
Please Select
Yes
No
If yes, what is the name of your current processor?
*
Are you currently applying for additional accounts? If yes, where?
*
Have you ever had a payment processing account terminated? If yes, why?
*
What is your average monthly processing volume?
*
Average chargeback rate over the last 120 days?
*
Do you currently have chargeback alerts? (RDR)
*
Please Select
Yes
No
Maximum ticket size?
*
Have ever been on the MATCH list?
*
Please Select
If yes, why?
*
Please verify that you are human
*
Submit
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