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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.

If you have any inquiries you may email us at sales@veripayment.com or call our toll free number
1-866-972-8765 or 1-866-923-7273 to speak to one of our Account Managers.

Business Information
This symbol ** denotes a required field.
Incorporation Name:**
Date of Incorporation:**
Country of Incorporation:**
Address:**
City:**
State or Province:
Zip or Postal Code:
Main Web URL:** http://
Industry:**
Website I.P. Address:
Web Server I.P. Address:
Administration Telephone Number:**
Administration Email Address:
Customer Support Telephone Number:
Technical Support Email Address:
Director Information
First Name:**
Last Name:**
Title:**
Date of Birth:**
Marital Status:**
City:**
State or Province:
Country:**
Telephone Number:**
Hours of Contact: (in Eastern Standard Time)** From to EST
Business Email Address: (must be under your business domain)**
Transaction Information
Expected Number of Transactions per month:
Expected Transaction Amount processed per month:** $ US
Maximum Single Transaction Amount: $ US
Average Charge Amount: $ US
Are you processing with a third party? Yes No
Have you ever processed with a third party before?** Yes No
If so, which company?
And for how long ?
Total Credit Card Sales for the Last 12 Months: $ US
Expected Percentage of Credit Cards by Phone: %
Expected Percentage of Credit Cards by Internet: %
Total Number of Chargebacks:
Total Amount in Chargebacks: $ US
Additional Merchant Websites
Website URL: http://
Website URL: http://
Website URL: http://
Website URL: http://
Other Information
Where did you hear about us:
Who were you referred by?
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