(800) 956-1277
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Congratulations !

You are on your way to increasing your sales and profits by accepting credit cards for your business. For your privacy and security, your account information is kept safe with the highest grade of commercially available encryption.
Please provide us with the information requested below to the best of your knowledge, fields that you don’t know or that you are not sure about please leave blank. Required items are marked with ( )

Merchant Information
Legal Name
*If sole proprietor enter your first and last name only, otherwise enter legal company name here
DBA Name
*(Doing Business As) This will appear on cardholder's statements as the charge
Company Contact Name
Best Phone Number to Reach Applicant
*Please enter numbers only no spaces or dashes
Email Address
Website Address
Business Phone Number
*Please enter numbers only no spaces or dashes
Fax Number
Please enter numbers only no spaces or dashes, if you don’t have fax number leave this field blank.
Business Address
Owner Information
Full Name
Home Address
Personal Phone number
*Please enter numbers only no spaces or dashes
Social Security
*Please enter numbers only no spaces or dashes
Date of Birth
*month/Day/Year
Ownership %
Business Information
Product Service Sold
*What type of product or service do you offer?
Type Of Ownership
Tax ID
*Please enter numbers only no spaces or dashes
Year Business Was Started
Time Frame from Transaction to Delivery (Must equal 100%)
* please enter % for example 50% 7 days 50% 14 days
Total Monthly Credit Card Sales (estimated)
*Please enter numbers only no commas, dollar signs or spaces
Average Individual Credit Card Sale Amount (estimated)
*Average transaction size in USD
Return and Refund Policies?
Please provide a breakdown of how credit card orders will be received, Please use best estimates , Must equal 100%
* please enter % for example 50% face to face (card swipe) 50% Internet
Would you like to accept American Express?
Currently processing credit card?
 
Have you ever had a credit card relationship terminated?
If you got terminated please provide the name of the processor or Bank
Reason for cancellation/termination (if any)
After completing the application and clicking the submit button you will be taken to Docusign to review your application and electronically sign it.

HighRiskPay.com is one of the leading High Risk Merchant Account providers of credit card processing & payment gateways to businesses with bad credit.

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