[md-form]

    [md-raw]
    *A legally binding court recognized contract will be generated automatically after form submission.
    [/md-raw]

    [md-radio label="Service"]
    PayPalStripeLocal Account[/md-radio]

    [md-raw]Customer Information[/md-raw]

    [md-text label="Main Contact Person"]
    [/md-text]

    [md-text label="Company Name"]
    [/md-text]

    [md-text label="Position"]
    [/md-text]

    [md-text label="Company Address"]
    [/md-text]

    [md-text label="Email Address"]
    [/md-text]

    [md-text label="Landline"]
    [/md-text] [md-text label="Landline Ext."] [/md-text]

    [md-text label="Mobile"]
    [/md-text]


    [md-raw]Bank Details[/md-raw]

    [md-text label="PayPal Account Name"][/md-text]
    [md-text label="PayPal Account Email"][/md-text]

    [md-raw]Business Information[/md-raw]

    [md-text label="Name of Authorized Person"]
    [/md-text]

    [md-text label="Job Title of Authorized Person"]
    [/md-text]

    [md-text label="Email Address of Authorized Person"]
    [/md-text]

    [md-text label="Business Name"]
    [/md-text]

    [md-text label="Business Website"]
    [/md-text]

    [md-raw]Support Information[/md-raw]

    [md-text label="Customer Support No. (must be US No.)"]
    [/md-text]

    [md-raw]Service Details[/md-raw]

    [md-select label="Setup Details"]
    [/md-select]
    [md-text label="Setup Cost (US$)"]
    [/md-text]

    [md-raw]Customer Information[/md-raw]

    [md-text label="Main Contact Person"]
    [/md-text]

    [md-text label="Company Name"]
    [/md-text]

    [md-text label="Position"]
    [/md-text]

    [md-text label="Company Address"]
    [/md-text]

    [md-text label="Email Address"]
    [/md-text]

    [md-text label="Landline"]
    [/md-text] [md-text label="Landline Ext."] [/md-text]

    [md-text label="Mobile"]
    [/md-text]


    [md-raw]Bank Details[/md-raw]

    [md-text label="Name on account"]
    [/md-text]

    [md-select label="Name of Bank"]
    [/md-select]

    [md-text label="Branch"]
    [/md-text]

    [md-text label="Account Number"]
    [/md-text]

    [md-text label="Routing Number"]
    [/md-text]

    [md-select label="Account Type"]
    [/md-select]

    [md-text label="Credit Card Statement Name"]
    [/md-text]
    [md-raw](This information will appear on your customers' credit card statements. You can edit it at any time. Use the name for your business that your customers will recognize to help prevent unintended chargebacks)[/md-raw]

    [md-raw]Business Information[/md-raw]

    [md-text label="Name of Authorized Person"]
    [/md-text]

    [md-text label="Job Title of Authorized Person"]
    [/md-text]

    [md-text label="Email Address of Authorized Person"]
    [/md-text]

    [md-text label="Business Name"]
    [/md-text]

    [md-text label="Business Tax No. (TRN/SSN/EIN)"]
    [/md-text]

    [md-text label="Business Website"]
    [/md-text]

    [md-text label="Business Category"]
    [/md-text]

    [md-textarea label="Business Description"]
    [/md-textarea]

    [md-select label="Estimated No. of transaction per month"]
    [/md-select]

    [md-text label="Average No. of transactions at peek"]
    [/md-text]

    [md-text label="Highest value of each transaction"]
    [/md-text]

    [md-text label="Average sales per month"]
    [/md-text]

    [md-text label="Average value of each transaction"]
    [/md-text]

    [md-text label="Estimated No. of refund per month"]
    [/md-text]

    [md-raw]For Stripe account setup:[/md-raw]

    [md-file label="Insert Identification Picture here. (Front View)"]
    [/md-file]

    [md-file label="Insert Identification Picture here. (Back View)"]
    [/md-file]


    [md-raw]Support Information[/md-raw]

    [md-text label="Customer Support No. (must be US No.)"]
    [/md-text]

    [md-raw]Service Details[/md-raw]

    [md-select label="Setup Details"]
    [/md-select]
    [md-text label="Setup Cost (US$)"]
    [/md-text]

    [md-raw]Customer Information[/md-raw]

    [md-text label="Main Contact Person"]
    [/md-text]

    [md-text label="Company Name"]
    [/md-text]

    [md-text label="Position"]
    [/md-text]

    [md-text label="Company Address"]
    [/md-text]

    [md-text label="Email Address"]
    [/md-text]

    [md-text label="Landline"]
    [/md-text] [md-text label="Landline Ext."] [/md-text]

    [md-text label="Mobile"]
    [/md-text]


    [md-raw]Bank Details[/md-raw]

    [md-select label="Name of Bank"]
    [/md-select]


    [md-raw]Business Information[/md-raw]

    [md-text label="Name of Authorized Person"]
    [/md-text]

    [md-text label="Job Title of Authorized Person"]
    [/md-text]

    [md-text label="Email Address of Authorized Person"]
    [/md-text]

    [md-text label="Business Name"]
    [/md-text]

    [md-text label="Business Tax No. (TRN/SSN/EIN)"]
    [/md-text]

    [md-text label="Business Website"]
    [/md-text]


    [md-raw]Support Information[/md-raw]

    [md-text label="Customer Support No. (must be US No.)"]
    [/md-text]

    [md-raw]Service Details[/md-raw]

    [md-select label="Setup Details"]
    [/md-select]
    [md-text label="Setup Cost (US$)"]
    [/md-text]

    [md-captcha]
    [recaptcha]
    [/md-captcha]

    [md-submit]

    [/md-submit]

    [/md-form]

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