Merchant Pre-Check Form

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

MonthDayYear
Date
Business Website
Business Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
SECTION 3: PROCESSING HISTORY
Applying Website
Do you have a members area?
Test Username
Test Password
Are you currently processing payments?
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?
If yes, explain reason
SECTION 4: FINANCIAL & BANKING
Monthly Revenue (Gross)
Anticipated Monthly Credit Card Volume
Bank Name
Bank Account Type
Routing Number
Account Number
SECTION 5: PRODUCT FULFILLMENT & CHARGEBACKS
How are the products/services delivered
Fulfillment timeframe
Do you offer recurring billing/subscriptions?
Chargeback ratio (last 6 months)
Refund ratio (last 6 months)
SECTION 6: RISK INDICATORS
Do you use affiliate marketing?
Do you sell internationally?
Is your business regulated (FDA, FTC, etc.)?
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
Should be Empty:

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