ePayMaker || Payment

ePAY-Payment Enablement Merchant Application Form

REQUIRED MERCHANT INFORMATION

New Acquiring Merchant Pre-Application Form

Please fill in the following form and return electronically

Company Name

Websites
(please provide ALL website URL’s)

Country of Incorporation

Company Registered Number

Founded Year

Name of UBO(s)

Nationality of UBO(s)

Contact Email Address

Contact Phone Number

Type of Business
(please add a brief description and Username/Passwords if applicable)

Is the business regulated or licensed?
IF YES,what type ofregulation/licence do you have?

Delivery time for goods
(orlength of membership)

Current Processing Profile

Are you currently accepting credit cards?

Yes If Yes, how long? Months

No (please provide 6 months Processing History if available)

Average Transaction Value

Monthly Sales Volume ($/£ per month)

Desired processing currencies

US-

EU-

Asia-

Rest of the world-

Desired processing currencies

MOTO (Mail/Telephone)-

Internet-

Do you require recurring transactions?

Yes

If you have any special requests, please let us know here

Transaction History

Month One

Month two

Month three

Month four

Month five

Month six

Monthly
Average

Chargeback Volume

Chargeback to Sales Ratio (%)

Registered Address

Full Name

Address Line 1

Address Line 2

City

State

Postal Code

Country