Are you a startup:
Yes No
Age of business:
Products/Services Sold:
How is your product/service sold:
Retail Storefront:
%
Mail Order:
Inbound Phone Sales:
Outbound Telemarketing:
Internet:
Total:
100%
Business Name:
*
Contact Name/Title:
* E-mail: *
Phone:
* Cell Phone:
Business Address:
City:
State: Zip:
Country:
Fax:
Website:
How were you referred to HighRiskMerchantServices:
Select One Google Yahoo MSN Other Other
Products/Services you are seeking:
Credit Card Terminal
Check Processing Terminal
Internet Gateway
Internet Virtual Terminal
US Based Merchant Account
Offshore Merchant Account
3rd Party Processing
Check Guarantee
ACH Processing
Check Conversion
ATM Machines
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, please explain in comments box below.
If so, by what banks/processors?
Who do you currently process with? (need last 3 months processing statements faxed to us: 702-947-5730)
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?
Select One Bad Fair Good Excellent
Credit Score:
Comments:
