Credit Card Payment Pre-Qualification Request

Reminder: Please fill out this form if you are currenctly seeking a merchant account. Please provide maximum details.

Personal Information

Title:	Mr. Ms. Mrs.
Full Name: (*)
E-mail address: (*)
Alternative Email address:
Company Designation:
Nationality:
Phone No.: (*)
Correspondence Address:
Yahoo Messenger ID :
MSN Messenger ID :
How do you know us?:	Yahoo Google MSN Yehey Other Search Engine Other Website Printed Media Friend's Recommendation I'm a regular visitor

Company Information

Legal/Corporate Name:: (*)
Year Established: (*)
Company e-mail address: (*)
Alternative Email address:
Phone Nos. :
Fax No.: (*)
Business Complete Address:
Does your company has an existing EU company registration?:	Yes No
If no, are you willing to have an EU company?:	Yes No

Business Model

Merchant Website (to be used in credit card acceptance) :
Website Industry :
Please describe your business model :
Does your company presently or in the past, accept credit card for processing? :	Yes No if yes please fill up the processing history
What is your Expected Monthly Volume Amount:	if no,
Expected Monthly Transaction :

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Payment Processing History and Information / Payment and Risk Management

Transaction Currencies :
Monthly Volume Amount :
Monthly Transaction Amount :
Former Processor :
Reasons for leaving :
Other payment methods used? :

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Security test. Please identify the pictures:
Click to identify Apple Cat Clock Dog Flower Fork Hammer Key Ship Tree	Click to identify Apple Cat Clock Dog Flower Fork Hammer Key Ship Tree	Click to identify Apple Cat Clock Dog Flower Fork Hammer Key Ship Tree

Notice: This form will assist your merchant services representative in setting up your merchant account.
Please fill out this form completely and click the submit button.

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Please DO NOT click the "Submit" button more than once.