High Risk Merchant Account Application

United States Based High Risk Internet Merchant Account Application

Step One - Merchant Information Required form fields are marked with ( * )

Do you wish to apply for Discover?	Yes No
Do you wish to apply for American Express?	Yes No
* DBA (Doing Business As) Name
* Best Contact Phone Number
* Legal Name of Business
* Company Contact First Name
* Company Contact Last Name
* Title or Relationship
* E-mail Address
Merchant Website URL
* Business Phone (e.g., 1112223333)
Business Fax
* Business Address
* Business City
* Business State/Country
* Business Zip Code

Step Two - Owner Information Required form fields are marked with ( * )
* Principal's First Name
* Principal's Last Name
* Date of Birth (e.g., 01/01/1965)	/ /
* Home Phone (e.g., 1112223333)
* Ownership %
* Home Address
* Home City
* Home State/Country
* Home Zip Code

Step Three - Business Information Required form fields are marked with ( * )
* Describe Products Sold (e.g., I sell CD's and DVD's)
* Business Ownership Type
* Home Business?	Yes No
Average Monthly Volume	$
* Average Sale/Ticket Amount	$
* Industry SIC Code
Years or Months in Business
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