Merchant Application Form


For more information, or assistance with multilevel merchant accounts, please fill out the inquiry form provided below and a Terminated Merchant Account representative will contact you within 24 hours.

Email Contact:info@adultmerchantaccount.us

Adultmerchantaccount.us
http://www.adultmerchantaccount.us

Fields marked with a * are required.

PRODUCTS / SERVICES

How were you referred to Adultmerchantaccount.us:

 Other

Products/Services you are seeking:

 

 

 

 Credit Card Terminal

 

 Check Processing Terminal

 Internet Gateway

 

 Internet Virtual Terminal

 US Based Merchant Account

 

 Offshore Merchant Account

 3rd Party Processing

 

 Check Guarantee

 ACH Processing

 

 Check Conversion

 ATM Machines

 

 

 
BUSINESS INFORMATION

Business Name:

*

Contact Name/Title:

*   E-mail: *

Phone:

*   Cell Phone:

Business Address:

City:

   State:    Zip:

Country:

Phone:

  Fax:

Website:

 

ABOUT YOUR BUSINESS

Are you a startup:

  

Age of business:

Products/Services Sold:

How is your product/service sold:

 

Retail Storefront:

%

 

Mail Order:

%

 

Inbound Phone Sales:

%

 

Outbound Telemarketing:

%

 

Internet:

%

 

Total:

100%

 

Current Monthly Volume:

$

 

 

 

Projected Monthly Volume:

$

 

 

 

Average Credit Card Transaction:

$

 

 

 

Highest Credit Card Transaction:

$

 

 

 


Have you ever been terminated
by a processor before?
If YES, please explain in
comments box below.


If so, by what banks/processors?

Who do you currently process with?

What banks/processors have you processed with in the past?

Why are you not with them anymore?

Who have you applied with so far?

How is the signers personal credit?

Credit Score:

Comments:

 

*Please add these two numbers 5 + 2 =
    



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