Pay Logic Merchant Application Form

Axe Payments Application Form
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Business Name*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Business Phone*

Area CodePhone Number
Business E-mail*
Business Website
Average Monthly Credit Sales:*
Estimated Transaction Amount*
Chip Card %
Keyed Manually %
Phone Order %
Internet Order %
Describe the Equipment You Use

POS SystemTerminalOnline/Gateway/Virtual Terminal
Are you in need of new or additional equipment?

YesNo
Agent Number
Upload a copy of your Merchant Statement

Upload a File

Cancelof
Please verify that you are human*
Should be Empty:

Axe Payments Application Form