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High Risk Pay Merchant
Contact Us
Media Room
Services
Merchant Services
High Risk Merchant Accounts
POS System for Small Businesses
Mobile Credit Card Processing for Small Businesses
Industries
Payment Processing Solutions for Auto Dealerships
Payment Processing Services for Veterinary Practices
Mobile Payment Solutions for Towing Companies
Net 30
Business Credibility Program
Business Credit Repair
Agent Program
Blog
Register
US Form
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 5
Business Information
Business Legal Name
*
DBA Name
Contact Name
*
Email Address
*
Website URL
*
Phone Number
*
Business Address
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Billing Address
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Business Type
*
--- Select Choice ---
E-commerce
Digital Products
Subscription Business
Consulting Services
Travel
Marketing Agency
Education
Financial Services
Years in Business
Tax ID / EIN
Monthly Processing Volume
Average Ticket Size
Highest Ticket Amount
Business Description / Products & Services
Next
Ownership Information
Owner Full Name
*
Ownership %
*
Date of Birth
*
SSN / Tax ID
*
Owner Email
*
Phone Number
Home Address
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Upload ID Proof
Drag & Drop Files,
Choose Files to Upload
You can upload up to 6 files.
Next
Compliance & Banking
Bank Name
*
Account Holder Name
*
Routing Number
*
Account Number
*
Processing History
Have you accepted cards before?
--- Select Choice ---
Yes
No
Chargeback Questions
PCI Compliance Questions
Next
Equipment & Site Inspection
Business Type
E-commerce
Retail
Digital Products
Consulting Services
Software / SaaS
Financial Services
Shipping Time
*
--- Select Choice ---
1–3 Business Days
3–5 Business Days
5–7 Business Day
7–14 Business Days
More than 14 Days
Not Applicable
Fulfillment Questions
Equipment Required?
Credit Card Terminal
Virtual Terminal
Payment Gateway
POS System
Mobile Card Reader
No Equipment Required
Terminal Type
Online Gateway
Virtual Terminal
Mobile Terminal
Restaurant Terminal
EBT Terminal
Additional Notes
Next
Documents & Signature
Upload Business License
Drag & Drop Files,
Choose Files to Upload
You can upload up to 6 files.
Upload Passport/ID
Drag & Drop Files,
Choose Files to Upload
You can upload up to 6 files.
Upload Bank Statement
Drag & Drop Files,
Choose Files to Upload
You can upload up to 6 files.
Upload Processing Statement
Drag & Drop Files,
Choose Files to Upload
You can upload up to 6 files.
Upload Void Check
Drag & Drop Files,
Choose Files to Upload
You can upload up to 6 files.
Upload Additional Document
Drag & Drop Files,
Choose Files to Upload
You can upload up to 6 files.
Digital Signature
Clear Signature
I agree to the Terms & Conditions and confirm that all submitted information is accurate.
*
I Agree
Document DBA Compliance
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