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*

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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*
MM slash DD slash YYYY
Business Address*
Street Address City ZIP / Postal Code
State*
Country*

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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 number less than or equal to 11.

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

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On Premise Sales %*
Please enter a number from 0 to 100.
Internet Order %*
Please enter a number from 0 to 100.
Mail Order %*
Please enter a number from 0 to 100.
Telephone Order %*
Please enter a number from 0 to 100.
Off-Premises Sales %*
Please enter a number from 0 to 100.
Sales Swiped %*
Please enter a number from 0 to 100.
Sales Keyed %*
Please enter a number from 0 to 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

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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, Max. file size: 50 MB.
2. Three months previous processing statements (if applicable). Cannot be a printout of the transaction summary.
Accepted file types: jpg, png, pdf, Max. file size: 50 MB.
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, Max. file size: 50 MB.
4. Marketing material: website, brochures and business card.
Accepted file types: jpg, png, pdf, Max. file size: 50 MB.
5. Copy of your driver’s license. Must match principal's name on pre-application.*
Accepted file types: jpg, png, pdf, Max. file size: 50 MB.
6. Phone script used for incoming customer/client calls.
Accepted file types: jpg, png, pdf, Max. file size: 50 MB.
7. EIN or SS4 Document*
Accepted file types: jpg, png, pdf, Max. file size: 50 MB.
8. Articles/LLC documentation/business license (if applicable)*
Accepted file types: jpg, png, pdf, Max. file size: 50 MB.
9. Price list for products/services.
Accepted file types: jpg, png, pdf, Max. file size: 50 MB.
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, Max. file size: 50 MB.

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High Risk Application

Step 1 of 6

Electronic Merchant Service