High Risk Merchant Account

High Risk Merchant Account
Name*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number

Business Type*
Legal Name*
DBA Name*
EIN*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Business Description*
Business Phone*

Area CodePhone Number
Fax*

Area CodePhone Number
Website*

Business Established On*

MonthDayYear
Have you ever accepted credit cards before?*

YesNo
Processing Parameters
Monthly CC Volume *
Average Ticket *
Highest Ticket *

Personal Information
Principal Name *

First NameLast Name
Date of Birth*

MonthDayYear
Driving Licence*
Issue Date*

MonthDayYear
Expire Date*

MonthDayYear
SSN*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone*

Area CodePhone Number
Should be Empty: