BUSINESS INFORMATION

Business Name

Business Tax No.

Business Address

Business Website

Business Category

Business Description

Estimated No. of transaction per month

Average No. of transactions at peek

Highest value of each transaction

Average sales per month

Average value of each transaction

Estimated No. of refund per month

PERSONAL INFORMATION

Legal Name

Job Title

Date of Birth

SSN

TRN

Home Address

CREDIT CARD STATEMENT DETAILS

Company Name (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)

Customer Support No. (must be US No.)

US Business Bank Account Details

Insert Identification Picture here. (Front View)

Insert Identification Picture here. (Back View)

I hereby certify that the information hereunder is correct to the best of my knowledge and understand that falsification of this information is grounds for refusal.

Name

Signature

Use your mouse to sign in the space below (use the clear button if there is a mistake).

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Date

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