South Florida Exclusive Broker
for T&A (TPMP) Parma, Italy

 

MERCHANT PRE-SCREENING FORM

 
Contact Information
Name of contact person that referred you (ISO) :
Last Name of Applicant :
First Name of Applicant :
Telephone Number of Applicant :
Country of Applicant :
International Dial Code of Applicant :
E-Mail Address of Applicant :

 
Business Information
Name of Business :
Date of Incorporation :
Name (Contracting Name) :
Doing Business As (DBA) :
Business Address :
Business Suite# :
Business City :
Business State :
Business Zip Code :
Business Country :
Nature of the Business (E-Commerce, Travel, etc.) :
Product(s) Description :
List ALL Relevant Websites (URLS) :
Website Owner's First Name :
Website Owner's Last Name :
Website Owner's Nationality :
Website Owner's Residential Address :
Website Owner's Residential Apt. # :
Website Owner's Residential City :
Website Owner's Residential State :
Website Owner's Residential Zip Code :
Website Owner's Residential Country :

 
Director Information
Director's Last Name :
Director's First Name :
Director's Title :
Director's Position :
Director's Address :
Director's Suite/Apt. # :
Director's City :
Director's State :
Director's Zip Code :
Director's Country :
Director's Telephone Number :
Director's Cell Phone Number :
Director's Fax Number :
Director's Passport Number :
Director's Passport Issuing Country :
Director's Driver's License Number :
Director's Driver's License Issuing Country :

 
Transaction Information
Expected Monthly Amount Processed (Volume) :
Expected Average Transaction Amount :
Currency :
Expected Currencies :
Percentage of Chargebacks (CB ratio) :
Chargeback history available : YES          NO
Are you dealing with any other bank for this business? : YES          NO
If so, what % will be with this new bank you are applying for? :
If requesting international 3rd party, what country are funds being transferred to? :
Have you had a Merchant Account closed? TMF (Terminated Merchant File) : YES          NO
Please Name Bank, or Processor: :
     

Digital Signature		   Wed, March 10, 2010
Today's Date
     
Need A: Terminal         Ethernet Terminal         Virtual Terminal
     

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