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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
Limited Company
Partnership
Sole Trader
Charitable Organization
PLC (Public Limited Company)
LLC
Other
Business model
Retail
Service
E-commerce
Online Gaming
Forex/Financial Markets
Lodging/Hotel
Financial Institution
Other
Customer Location(s)
EU
EEA
EMEA
APAC
ANZ
NORAM
How do you acquire customers?
Online Advertising
Repeat Business
Magazine/Offline Advertising
Word of Mouth
Search Engine Traffic
Price Comparison Website
Other
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)
Terms & Conditions
Privacy Policy
Shipping Policy
Cookie Policy
Returns Policy
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.)
Under what conditions are customers allowed to exceed above limits
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