Business Merchant Application

Basic Information

Lead Source:

Select the region:

Application Date:

Application IP:

Company Name:

Payments Type:

Application Type:

Business (KYB) Details

Legal Business Name:

DBA (Doing Business As):

Business Address:

City:

State:

ZIP:

Country:

Business Phone:

Website URL:

Corporate Type:

TIN / EIN:

Representative (KYC) Details

First Name:

Last Name:

Role/Relationship:

Mobile Number:

Email Address:

SSN / Passport ID:*

Banking / Payout Information

Bank Name:

Bank Account #:

Routing / SWIFT / IBAN:

Account Holder Name:

Bank Account Type:

Bank Location:

Business (KYB) Details (cont.)

Industry/MCC Code:

Country of Incorporation:

Date of Incorporation:

Company Registration Number: ( For International )

Ownership Structure:

Driver Licence Number:

State of Driver Licence

Representative (KYC) Details (cont.)

Principal Address:

Date of Birth:

Home Address:

City:

State:

ZIP:

Country:

Ownership %:

Principal Title:

Processing Details

Projected Monthly Volume:

Current Monthly Volume:

Currency:

Processing Type:

Sales Type:

Risk Category:

Chargeback % Avg:

RDR:

YES

Boarding Platform:

Back Processor:

MID Assigned:

Country:

Boarded URLs:

Boarding Date:

Go Live Date:

Documentation / Compliance

KYC/KYB Documents Upload:

Business License:

Articles of Incorporation:

Utility Bill / Proof of Address:

Refund / Shipping Policy:

Dropbox Backup Files: Accepted: PDF, PNG, GIF, JPG. You can select multiple files.

Dropbox/External Backup Link: Provide a link to a Dropbox or other backup location.

Voided Check / Bank Letter:

Do you currently have or previously had any other merchant accounts (live or cancelled)?

Have you ever been terminated or placed on the MATCH blacklist by card brands?

Have you ever filed for bankruptcy?

Comments: