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Email

Merchant’s Legal Business Name

Registered Address

Country

State

City

Business Telephone

Contact Name

Customer Service Phone

Business Fax

“Doing Business As/Trading as” Name

Country

State

City

Business Website

Type of Ownership

Business model

Company Registration No

Date of Incorporation

VAT No. (or equivalent)

Other Branches/Agencies

Please fully describe the exact nature of your business

Shareholder No:1

Full Name

Title

Date of Birth

Nationality

Home Phone

Residence Address

Own Rent

City

State

Zip

Years at this Address

% Percentage Owned

Share Value

Have you or any other directors, shareholders, ultimate beneficiary owners or other persons connected with the business mentioned in this application form ever received a criminal conviction/prosecution or have any convictions/prosecutions pending (other than minor traffic offenses, not involving prison)?

Yes No

Are there any ongoing investigations or inquiries by or on behalf of any government or other body in respect of the affairs of your company, and any of its subsidiaries or parent company?

Yes No

Has the company received cautions, fines or been banned from operating within any jurisdiction?

Yes No

Domain(s) (Please list all domain names)

Domain name 1

Domain name 2

Domain name 3

Please tick what information is available on website(s)

Legal Info (Company Name, Registration Number, Contact Details and applicable disclaimer)

PAYMENT PROCESSING DETAILS

Select which of the methods below you will be using

SEPA

Yes No

For the Next 12 Months (estimated/expected):

Average Transaction Value (ATV)

No. of Transactions

SWIFT

Yes No

Currency

EUR (€) GBP (£) USD ($)

Average Transaction Value (ATV)

No. of Transactions

Card Present Card-Non-Present

Date Of Incorporation

Descriptor

(What you want your client to see on their bank statement)

Merchant Fulfilment Period

Do You Offer An E-Wallet

How Many Staff Do You Employ

Do You Process Recurring Payments

Target Markets in %

EU/EEA %

UK %

USA %

ROW %

Banking Details

Account Country

Account Currency

Account Holder Name

Bank Name

IBAN

Swift/BIC

Special Requirements

Services Required

Ecommerce

Yes No

Point Of Sale (machine)

Yes No

MOTO (telephone)

Yes No

Do You Currently Offer Amex

Do You Wish To Offer Amex

Do You Requires DCC (Dynamic Currency Conversion)

Currencies Required

For the Next 12 Months (estimated/expected):

12 Month Projected Turnover

Average Transaction Value (ATV)

No. of Transactions

Chargeback %

Refund %

Crypto

Yes No

Coin Type

Bitcoin (₿) Ethereum (Ξ) Tether (₮)

For the Next 12 Months (estimated/expected):

Average Transaction Value (ATV)

No. of Transactions

Settlement:

SEPA SWIFT CRYPTO

Do you have permanent customers?

Yes No

Do you have VIP customers?

Yes No

Are you using Preauthorization?

Yes No

Do you have a customer support centre?

Yes No

Can you separate new customers from permanent ones?

Yes No

Are you currently using a fraud prevention system?

Yes No

Please describe the fraud prevention systems, if you answered yes to the previous question

Describe all velocity controls (i.e. a limitation of the number of times the credit card can be used in a given day/week/month, or a limitation of the amount spent, etc.)

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Shareholder No:1

Domain(s) (Please list all domain names)

PAYMENT PROCESSING DETAILS

Select which of the methods below you will be using

For the Next 12 Months (estimated/expected):

(What you want your client to see on their bank statement)

Target Markets in %

Banking Details

Services Required

For the Next 12 Months (estimated/expected):

For the Next 12 Months (estimated/expected):

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Important Links

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