Payment Gateway Application

Please fill out the form below and we'll get you approved for a new payment gateway and you'll be able to accept credit cards online right from your website or shopping cart.
To continue with the application:
-You must have a merchant account (if you need a merchant account please go here).
-Your business must be based in the United States.

Your Contact Details
Fullname

First Name
Last Name
Email
Phone
Area CodePhone Number
SSN (Last 4 digits)
Date of Birth
Month - Day - Year
Business Details
Business Name
Website Address
How is your business entity classified by the IRS?
Please enter your DBA (Doing Business As) name.
DBA Phone Number

DBA Address

Street Address
Street Address 2
City	State / Province
Postal / ZipCode	Country

Is your Legel Business Name and Legal Business Address exactly the same as your DBA name and DBA address?

Yes
No
Please enter your Legal Business name.

Legal Business Address

Street Address
Street Address 2
City	State / Province
Postal / ZipCode	Country

Billing Information
Please enter your credit card information below. The initial setup and monthly payment gateway fees will be debited from this card.
Name On Credit Card

First Name
Last Name
Credit Card Number
\b\d{13,16}\b
Credit Card Expiration
CVV Code (3 or 4 digit number on card)
Credit Card Billing Address

Use DBA Business Address
Use Legal Business Address
Use Another Address

Billing Address

Street Address
Street Address 2
City	State / Province
Postal / ZipCode	Country

Captcha

Payment Gateway Application

Your Contact Details

Business Details

Billing Information

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