How did you here about us? (Please be specific: eg. URL or search engine + words used)

Full Name:

e-mail address:

Your Site:

 

Are you the owner of the business? Yes  No

What country does the owner of the business live in?

Is your WWW Host located in the US? Yes  No          (This is required for a Merchant Account)

Do you already own a US Corporation?Yes  No

Do you already have a United States Bank Account at a bank located in the US? Yes  No

Have you ever had a US Merchant Account before? Yes   No

Does the owner have a US Credit Rating Yes   No If Yes is it no us credit rating bad credit fair credit good credit great credit

How is the owners credit rating at home pick your credit rating bad credit fair credit good credit great credit

 

Business Info:

What do you sell?

How do you sell it?

How much is your average sale?

What is your expected monthly sales?  eg. $8,000-$10,000 to start: in 6 months

Who is your target market (geographically)?  eg. americans

Orders: %Internet   %Telephone      %Mail Order   %Card Present

Years in business (New is OK)

 

Mailing Address
Name:
Address:
City:
State/Province:
ZIP/Postal code:
Country:
	Please Re-enter exactly as it would appear an a Mailing Label
line 1
line 2
line 3
line 4
line 5
Phone :
Fax :

 

Any further comments or questions:

 

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