Company Details

1. REGISTERED COMPANY NAME*

2. REGISTRATION NUMBER*

3. REGISTERED ADDRESS*

No. AND STREET NAME

CITY

COUNTRY

POSTAL CODE

4. TRADING Address* (CHECK HERE IF SAME AS ABOVE)

No. AND STREET NAME

CITY

COUNTRY

POSTAL CODE

5.BUSINESS & INDUSTRY TYPE*

PRODUCT/SERVICES OFFERED

WHAT WILL THE CARDHOLDER PAY FOR THROUGH YOUR WEBSITE

HOW ARE THE PRODUCTS MARKETED

6. URL/S*

7. PROCESSING TRAFFIC-COUNTRIES WHERE
PRODUCT/SERVICES ARE BOUGHT *

Company Bank Details

8. ACCOUNT COUNTRY*

Director & Shareholders

9. DIRECTOR/SHAREHOLDERS LOCATION (COUNTRY)*

Company Sales

10.ARE YOU CURRENTLY ACCEPTING CARD PAYMENTS*

IF YES PLEASE PROVIDE THE NAME OF THE PROVIDER

11. CARD ACCEPTING DETAILS(TICK WHERE APPLICABLE)

12. PROJECTED ANNUAL TURNOVER CITY

TO CALCULATE THE VALUE OF RISK

13. AVERAGE TRANSACTION VALUE

TO CALCULATE THE VALUE OF RISK

14. CHARGEBACKS-VALUE AND COUNT OVER 6 MONTHS

TO CALCULATE THE VALUE OF RISK

15. REFUNDS-VALUE AND COUNT OVER 6 MONTHS

TO CALCULATE THE VALUE OF RISK

WHAT IS THE PROJECTED DELIVERY DELAY?(IN DAYS)

17. IS A LICENSE REQUIRED?(TRICK WHERE APPLICABLE)

IF YES PLEASE GIVE DETAILS TO THE LICENSE HELD

(PLEASE INCLUDE REGULATORY NAME/ JURISDICTION/LICENSE NO.)

FORM CREATION DATE*

PARTNER NAME*

COMMERCIAL OWNER NAME*