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Contact Information

First name

Last name:

Title/Position:

E-Mail

Cell phone

Business Phone

Business Fax

How did you hear about us?

Owner Information

First Name

Last name:

% of ownership

SSN (US only)

Date of birth

Business Information

Industry type:

Legal Corporation Name:

Doing business as:

Website Address:

Date of Business Startup or Incorporation:

Years open:

What Type Of Company?

If Other Please Specify:

Federal Tax ID:

How Many People Work In Your Organization?

Number of locations

Seasonal business?

Do you operate from store / retail or Online?

Do you have any Federal or state tax lien?

Is your business for sale?

Have you ever filed for bankruptcy?

Business Address

Country:

State:

(required for US companies only)

Business Street Location:

Zip/Postal code:

City:

Mailing Address

Country:

State:

(required for US companies only)

Address:

Zip/Postal code:

City:

Owner Address

Country:

State:

(required for US companies only)

Address:

Zip/Postal code:

City:

Cellphone:

Home phone:

How many years spent living at the current address?

How many years spent living at the Previous address?

Transaction Information

Principal currency

Do you accept credit card?

Do you accept Echeck / ACH?

Current processor name:

Time with processor

Reason for leaving

Have you been blacklisted by Visa or MC?

Monthly Trading Volume:

Average Transaction Value:

Number of transaction per month

Time From Order To Delivery:

Second Owner information

First Name

Last name:

% of ownership

SSN (US only)

Date of birth

Second Owner Address

Country:

State:

(required for US companies only)

Address:

Zip/Postal code:

City:

Cellphone:

Home phone:

How many year spent living at the current address?

How many year spent living at the Previous address?

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My business is not related to the internet casino or gambling industry

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