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How were you referred to High Risk

Products/Services you are seeking:

Business Name: *

Contact Name/Title: *

E-mail: *

Phone: *

Business Address: *

City:

State:

Zip:

Country:

Website:

Are you a startup:
YesNo

Age of business:

Products/Services Sold:

How is your product/service sold:

Retail Storefront:

Mail Order:

Inbound Phone Sales:

Outbound Telemarketing:

Internet:

Current Credit Card Processor / Bank:

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,
YesNo

please explain in comments box below.

If so, by what banks/processors?

Who do you currently process with?

What banks/processors have you processed with in the past?

Why are you not with them anymore?

Who have you applied with so far?

How is the signers personal credit? : *

Credit Score:

Comments:

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