Merchant Sign Up | Merchant Accounts | Credit Card Processing Solutions

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Merchant Sign Up

Thank you for considering VeriPayment.com as your online payment gateway solution. This form will allow us to undertake a rapid business assessment of your company as a potential merchant of VeriPayment.com. It is secure, and any information that you provide will only be used for the purposes of assessing your application.

Once filled out and submitted, your account will be automatically created. One of our Account Managers will then get in contact with you within 24hrs.

Business Information This symbol ** denotes a required field.
Incorporation Name:**
Address:**
City:**
State or Province:
Zip or Postal Code:
Main Web URL:**	http://
Administration Telephone Number:**
Administration Email Address:
Technical Support Email Address:
Director Information
First Name:**
Last Name:**
Title:**
City:**
State or Province:
Telephone Number:**
Business Email Address: (must be under your business domain)**
Transaction Information
Expected Number of Transactions per month:
Expected Transaction Amount processed per month:**	$ US
Average Charge Amount:	$ US
Have you ever processed with a third party before?**	Yes No
Expected Percentage of Credit Cards by Phone:	%
Expected Percentage of Credit Cards by Internet:	%
Additional Merchant Websites
Website URL:	http://
Website URL:	http://
Other Information
Where did you hear about us:
Who were you referred by?
Reload Image	Please enter the characters of the image:

Email

Credit Cards
E-checks
Western Union
Debit Cards