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CREDIT CARD PROCESSING INFORMATION

Card Present %:

Card Swiped %:

Internet %:

Card Not Present %:

Mail / Phone Order %:

B2B %:

Monthly CC Volume: $

Monthly Amex Volume: $

Average Ticket: $

Max High End Ticket: $

PIN DEBIT:

Personal Guarantor:

Products/Services Sold:

% Time of Sale

% 1-7 Days

% 8-14 Days

% 15-30 Days

% 30+ Days (Must Equal 100%)

EQUIPMENT / SITE INFORMATION

Gateway/Billing Software/Virtual Terminal/Card Present

Batch: (not applicable to Visp clients)

Auto Batch Time: (not applicable to Visp clients)

Discount (fees billed):

3rd Party Fulfillment: (if applicable)

Where is Product/Equipment Stored: (if applicable)

Fulfillment Name/Address (if applicable):

Solution Requested:

Detailed Description of Business/Industry:

Ever been denied approval or had your merchant account closed?

If Yes please explain -

What currencies would you like to process in?

What currencies would you like to settle (deposit) as?

Countries you do business in listed by % breakdown?

BANKING INFORMATION (US Format)

DEPOSITORY ACCOUNT:

Routing #:

Account #:

BILLING ACCOUNT (FOR FEES) – IF DIFFERENT THAN DEPOSITORY:

Routing #:

Account #:

OWNERSHIP INFORMATION

** Info Required for ALL 20% or more owners **

Legal Name:

Title:

% of Ownership:

Date of birth:

SSN/SIN:

Email:

Phone:

Home Address:

Own or Rent:

How long at address:

DL or ID#/ExpDate/State:

BENEFICIAL OWNER #2

(if 20% or more ownership)

Legal Name:

Title:

% of Ownership:

Date of birth:

SSN/SIN:

Email:

Phone:

Home Address:

Own or Rent:

How long at address:

DL or ID#/ExpDate/State:

BENEFICIAL OWNER #3

(if 20% or more ownership)

Legal Name:

Title:

% of Ownership:

Date of birth:

SSN/SIN:

Email:

Phone:

Home Address:

Own or Rent:

How long at address:

DL or ID#/ExpDate/State:

BENEFICIAL OWNER #4

(if 20% or more ownership)

Legal Name:

Title:

% of Ownership:

Date of birth:

SSN/SIN:

Email:

Phone:

Home Address:

Own or Rent:

How long at address:

DL or ID#/ExpDate/State:

MANAGER / MANAGING INDIVIDUAL

Name

Title:

% of Ownership:

Date of birth:

SSN/SIN:

DL or ID#/ExpDate/State:

Phone:

Email:

Address

ADDITIONAL CONTACT FOR THE BUSINESS

(if applicable)

CONTACT PERSON

EMAIL ADDRESS

PHONE NUMBER

ROLE W/COMPANY

CAPTCHA

1-541-955-6900

success@visp.net

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Company Information

CREDIT CARD PROCESSING INFORMATION

EQUIPMENT / SITE INFORMATION

BANKING INFORMATION (US Format)

OWNERSHIP INFORMATION

BENEFICIAL OWNER #2

BENEFICIAL OWNER #3

BENEFICIAL OWNER #4

MANAGER / MANAGING INDIVIDUAL

ADDITIONAL CONTACT FOR THE BUSINESS