High Risk Merchant Account Provider | High Risk Processing

Legal Name of Business*
DBA (Doing Business As)*
Owner First Name*
Owner Last Name*
Email*
Phone*
Time Zone*

Save and Continue Later

Website
Do you sell your product or service using a free trial offer?*
- Yes
- No
Business Phone*
Federal Tax ID*
Years of Ownership
Months of Ownership*
Types of goods/Services you sell*
Business Type*
- Sole Propreitor
- Partnership
- Corporation
- LLC
Business Zoning*
- Commercial
- Residential
- Industrial
Business Start Date*
Business Address*
Street Address City ZIP / Postal Code
State*
Country*

Save and Continue Later

Owner Name*
First Last
Driver's License or ID*
Social Security Number or National ID Number*
Ownership %*
Owner Address
Street Address City ZIP / Postal Code
State*
Country*
Do you rent or own?*
- Rent
- Own
Years at Residence Location*
Months at Residence Location*
Please enter a value less than or equal to 11.

Save and Continue Later

Estimated Monthly Card Sales*
Average Single Sale Amount*
Maximum Single Sale Amount*
Business Transaction Type
- Retail
- Mail/Phone Orders
- Internet

Save and Continue Later

On Premise Sales %*
Please enter a value between 0 and 100.
Internet Order %*
Please enter a value between 0 and 100.
Mail Order %*
Please enter a value between 0 and 100.
Telephone Order %*
Please enter a value between 0 and 100.
Off-Premises Sales %*
Please enter a value between 0 and 100.
Sales Swiped %*
Please enter a value between 0 and 100.
Sales Keyed %*
Please enter a value between 0 and 100.
Bank/Financial Institute Name*
Routing #*
Account #*
Have you ever had a merchant account terminated?*
- Yes
- No
TMF/MATCH
Would you like to accept American Express*
- Yes
- No
Has any principle filed bankruptcy?*
- Yes
- No
Do you currently accept Visa/MasterCard/Discover?*
- Yes
- No

Save and Continue Later

1. Pre-printed voided check or a signed bank letter dated in the last 30 days with the routing and account numbers. Cannot be a starter check. DBA or legal name must be printed on check.*
Accepted file types: jpg, png, pdf.
2. Three months previous processing statements (if applicable). Cannot be a printout of the transaction summary.
Accepted file types: jpg, png, pdf.
3. Three months business checking account statements. Cannot be a printout of the transaction summary.*
Substitute personal checking statements if there are no business checking statements.
Accepted file types: jpg, png, pdf.
4. Marketing material: website, brochures and business card.
Accepted file types: jpg, png, pdf.
5. Copy of your driver’s license. Must match principal's name on pre-application.*
Accepted file types: jpg, png, pdf.
6. Phone script used for incoming customer/client calls.
Accepted file types: jpg, png, pdf.
7. EIN or SS4 Document*
Accepted file types: jpg, png, pdf.
8. Articles/LLC documentation/business license (if applicable)*
Accepted file types: jpg, png, pdf.
9. Price list for products/services.
Accepted file types: jpg, png, pdf.
10. ecommerce ONLY: Complete description of goods and services, customer service contact information including email address and phone number, delivery policy must be clearly stated, price for product or service, privacy policy specifying use of customer data, information on when the card is charged, active shopping cart, secure method for the transmission of payment data (SSL Secured 128 bit).*
Accepted file types: jpg, png, pdf.

Save and Continue Later

High Risk Application

Step 1 of 6

Electronic Merchant Service