High Risk Merchant Account
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Legal Business Name:
Doing Business As:
Business Address:
City, State, Zip:
Country:
Business Form:
Corporation
Limited Liability Company
Sole Proprietorship
Other
Federal Tax ID:
Business Phone:
Business Fax:
Email Address:
Website Address:
Transaction Type:
Website Transactions
Phone Transactions
Face To Face Sales
Other
Describe Products:
Accepted Cards In Past:
Yes
No
Accept Cards Now:
Yes
No
Processing Statements:
3 Months Available
6 Months Available
1 Month Available
None
Business Start Date:
Average Sale Price:
Monthly Card Volume:
STEP TWO
Owner Information
Owners Name:
Home Address:
City, State, Zip
Country:
Home Phone:
Cell Phone:
Best Phone:
Principal Title:
President
LLC Member
Owner
None
Ownership %:
100% Ownership
50% Ownership
Less Then 50% Ownership
None
Social Security Number:
Date Of Birth:
Years Of Ownership:
All Rights Reserved 2007
