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ePAY-Payment Enablement Merchant Application Form

REQUIRED MERCHANT INFORMATION

New Acquiring Merchant Pre-Application Form

Please fill in the following form and return electronically

Current Processing Profile

US-
%
EU-
%
Asia-
%
Rest of the world-
%
MOTO (Mail/Telephone)-
%
Internet-
%

Transaction History

Month One

Month two

Month three

Month four

Month five

Month six

Monthly
Average

Registered Address