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Business Information
Business Name
Operating Address
Address 2
City
State/Zone
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Postal Code
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Website Address
Country of Origin
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Albania
Algeria
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Germany
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Isle of Man
Israel
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Jordan
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Latvia
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Monaco
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Albania
Algeria
Austria
Bahrain
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Egypt
Estonia
Faroe Islands
Finland
France
France, Metropolitan
Germany
Gibraltar
Greece
Guernsey
Hungary
Iceland
Iraq
Ireland
Islamic Republic of Iran
Isle of Man
Israel
Italy
Jersey
Jordan
Kuwait
Latvia
Lebanon
Liberia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malaysia
Malta
Mexico
Moldova, Republic of
Monaco
Montenegro
Morocco
Netherlands
Norway
Oman
Palestine Authority
Poland
Portugal
Qatar
Republic of Serbia
Romania
San Marino
Saudi Arabia
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Syrian Arab Republic
Tunisia
Turkey
United Arab Emirates
United Kingdom (Great Britain)
United States
Yemen
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Business Billing Information
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Bjelovarsko-bilogorska županija (Bjelovar)
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Dubrovačko-neretvanska županija (Dubrovnik)
Grad Zagreb (Zagreb)
Istarska županija (Pazin)
Karlovačka županija (Karlovac)
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Ličko-Senjska županija (Gospić)
Međimurska županija (Čakovec)
Osječko-baranjska županija (Osijek)
Požeško-slavonska županija (Požega)
Primorsko-goranska županija (Rijeka)
Šibensko-kninska županija (Šibenik)
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Splitsko-dalmatinska županija (Split)
Varaždinska županija (Varaždin)
Virovitičko-podravska županija (Virovitica)
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Albania
Algeria
Austria
Bahrain
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Egypt
Estonia
Faroe Islands
Finland
France
France, Metropolitan
Germany
Gibraltar
Greece
Guernsey
Hungary
Iceland
Iraq
Ireland
Islamic Republic of Iran
Isle of Man
Israel
Italy
Jersey
Jordan
Kuwait
Latvia
Lebanon
Liberia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malaysia
Malta
Mexico
Moldova, Republic of
Monaco
Montenegro
Morocco
Netherlands
Norway
Oman
Palestine Authority
Poland
Portugal
Qatar
Republic of Serbia
Romania
San Marino
Saudi Arabia
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Syrian Arab Republic
Tunisia
Turkey
United Arab Emirates
United Kingdom (Great Britain)
United States
Yemen
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EBT PIN Debit
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Mo. Transfer ($)
Cash Incentive
Percent
Wealth Builder
Percent
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Owner Information
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Ownership Percentage
Years at Address
Email
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State
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Bjelovarsko-bilogorska županija (Bjelovar)
Brodsko-posavska županija (Slavonski Brod)
Dubrovačko-neretvanska županija (Dubrovnik)
Grad Zagreb (Zagreb)
Istarska županija (Pazin)
Karlovačka županija (Karlovac)
Koprivničko-križevačka županija (Koprivnica)
Krapinsko-zagorska županija (Krapina)
Ličko-Senjska županija (Gospić)
Međimurska županija (Čakovec)
Osječko-baranjska županija (Osijek)
Požeško-slavonska županija (Požega)
Primorsko-goranska županija (Rijeka)
Šibensko-kninska županija (Šibenik)
Sisačko-moslavačka županija (Sisak)
Splitsko-dalmatinska županija (Split)
Varaždinska županija (Varaždin)
Virovitičko-podravska županija (Virovitica)
Vukovarsko-srijemska županija (Vukovar)
Zadarska županija (Zadar)
Zagrebačka županija (Zagreb - okolica)
ZIP Code
Previous Street Address (if current is under 2 years)
Years at Address
City
State
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Bjelovarsko-bilogorska županija (Bjelovar)
Brodsko-posavska županija (Slavonski Brod)
Dubrovačko-neretvanska županija (Dubrovnik)
Grad Zagreb (Zagreb)
Istarska županija (Pazin)
Karlovačka županija (Karlovac)
Koprivničko-križevačka županija (Koprivnica)
Krapinsko-zagorska županija (Krapina)
Ličko-Senjska županija (Gospić)
Međimurska županija (Čakovec)
Osječko-baranjska županija (Osijek)
Požeško-slavonska županija (Požega)
Primorsko-goranska županija (Rijeka)
Šibensko-kninska županija (Šibenik)
Sisačko-moslavačka županija (Sisak)
Splitsko-dalmatinska županija (Split)
Varaždinska županija (Varaždin)
Virovitičko-podravska županija (Virovitica)
Vukovarsko-srijemska županija (Vukovar)
Zadarska županija (Zadar)
Zagrebačka županija (Zagreb - okolica)
ZIP Code
Processing information
Previous processor
Refund Policy (none, 30days, exchange only, etc.)
Terminal(s) Brand & Model
Terminal(s)
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Own
Purchase
Rent
Quantity
Cost Each
Statement Delivery Preference
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Email
Company Address
Charge Back Delivery Preference
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Email
Company Address
Processing Information
Annual Volume ($)
Average Ticket ($)
Highest Ticket ($)
Projected Monthly Sales
Projected Yearly Sales
Highest Ticket Frequency
According to the Merchant Agreement for Transaction Services, it is necessary for Merchant to provide its banking information to facilitate billing and payments. The Merchant must inform the Processor of any changes to its banking details and accounts. The Processor will not be liable for any funds incorrectly transferred due to a change in banking information or errors that directly resulted from the information provided by Merchant. Merchant authorizes the Processor to debit from the Merchant’s bank account all monthly payments and other amounts owed to the Processor related to the Transaction Services. This authorization shall remain in effect after termination of the authorization shall remain in effect after termination of the Agreement and for as long as Merchant owes any amounts to the Processor. Merchant agrees that the Processor will not be liable for any loss or damage incurred as a result of anything done or not done according to this authorization. If the account is transferred to another branch or the account is closed, and an account is opened at another bank, this authorization shall have the same force and effect as if it originally was directed to that branch or bank. The undersigned Guarantors acknowledge and agree to be bound by all the terms and conditions of this Agreement and unconditionally guarantee the performance of this Agreement. By signing below, Merchant (I) represents that the information provided by Merchant in this Agreement is accurate, complete, and not misleading; (II) acknowledges that Merchant has read and understands this Agreement and Operating Procedures and agrees to be bound by their terms; and (III) authorizes the Processor and its agents to credit and debit the Designated Automatic Funds Transfer Account in accordance with this Agreement.
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