Merchant Application Form

How were you referred to High Risk Credit Card Processor:

Select One Google Yahoo MSN Other  Other

Products/Services you are seeking:

Business Name:

*

Contact Name/Title:

*   E-mail: *

Phone:

*   Cell Phone:

Business Address:

City:

   State:    Zip:

Country:

Phone:

  Fax:

Website:

Are you a startup:

Yes    No

Age of business:

Products/Services Sold:

Current Monthly Volume:

$

Projected Monthly Volume:

$

Average Credit Card Transaction:

$

Highest Credit Card Transaction:

$

Have you ever been terminated
by a processor before?
If YES, please explain in
comments box below.

Yes      No

How is the signers personal credit?

Select One Bad Fair Good Excellent

Credit Score:

Comments: