CONTACT US DOMAIN REGISTRATION FAQ
Address*
City*
State*
Zip*
Phone*
Fax*
Email*
EST MST CST PST OTHER Time Zone
Website Address
Federal Tax ID*
DBA Name*
DBA Address*
DBA City*
DBA State*
DBA Zip Code*
DBA Contact*
DBA Phone*
Time In Business* 1 Year Or Less 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years Longer Than 10 Years
Products and Services Sold*
Merchant Type:* Retail - Select this only if you have a physical walk-in storefront. Restaurant - Select this if you are a Restaurant. Lodging - Select this if you are a Hotel/Motel. Internet Gateway - Select this if you wish to process sales via the Internet. Mail Order - Select this if you process phone & fax sales but NOT primarily via the Internet Wireless - Select this if you wish to process mobile transactions from a kiosk or off-site location Other
Monthly Volume*
Average Amount*
Highest Amount*
Percent Ownership*
SSN1* (These must be separate fields)
SSN2* (These must be separate fields)
SSN3* (These must be separate fields)
Zip Code*
Date Of Birth*
Please Rate Your Personal Credit Score To The Best Of Your Knowledge * Select Excellent - FICO score > 700 Average - FICO score 625-700 Low - FICO score 576-624 Poor - FICO score 500-575 Very Poor - FICO score < 500
Percent Ownership
SSN1
SSN2
SSN3
Phone
Address
City
State
Zip Code
Date Of Birth
Please Rate Your Personal Credit Score To The Best Of Your Knowledge Select NA Excellent - FICO score > 700 Average - FICO score 625-700 Low - FICO score 576-624 Poor - FICO score 500-575 Very Poor - FICO score < 500
Has your business or any principal been terminated as a VISA/MC merchant? No Yes Has your business or any principal filed bankruptcy or been subject to involuntary bankruptcy? No Yes
Registered Domain Name (if actual site not yet completed)
Retail Location Office Building Residence
Own or Rent?
Own Rent
If Rent, Landlord Name:
*
Contact Name (1)
Contact Phone (1)
Business Name (2)
Contact Name (2)
Contact Phone (2)
