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2015 Merchant Application Form
mrutherford
2017-01-25T11:17:55+00:00
Merchant Application Form
Please note all fields are mandatory
PSP
*
For JetPay usage only
Date
*
1
. Company Information
Merchant name
*
Merchant Company Details
First name
*
Merchant Owner's Details
Email
*
Merchant Owner's Details cont'd
Merchant URL
*
Last name
*
Switchboard tel
*
Business address
*
Home address
*
Mobile no.
*
Direct line
*
Town/City
*
Town/City
*
Ownership (%)
*
Zip/Postcode
*
Zip/Postcode
*
Trading history (years)
*
Country
*
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
*
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Nationality
*
2
. Merchant Website Information
Merchant Company Details
Current DBA name
*
DBA name
Yes / No
*
Dynamic Descriptors Required?
Yes / No
*
3DS Required?
Your current MCC code here...
MCC code
Your (new) proposed MCC code here...
New MCC code
Yes / No
Are you PCI DSS compliant?
-- Select all that apply --
Currencies required - multiselect
US Dollar
CAN Dollar
Aus Dollar
UK GBP
Euro
JPN YEN
3
. Processing & Authorisation Information
Transaction Details
Example: 2,500,000
Expected monthly volume (EUR) that will be processed by JetPay
0
European traffic (%)
0
US traffic (%)
0
Rest of World traffic (%)
Example: 285,000
Expected monthly count of transactions
Example: €300k
Maximum monthly volume in EUR (capped)
Example: 8.0
Average ticket value (EUR)
% Debit Cards
% Volume split between...
% Credit Cards
... and ...
-------------
IMPORTANT
6 months processing history and chargebacks are required in order to complete your application.
Visa
% Volume split between...
Mastercard
... and ...
% Volume - Visa/MC blended
Current chargeback ratio (1)
% Count - Visa/MC blended
Current chargeback ratio (2)
% Ratio - Volume / Count
Current chargeback ratio (3)
Expected Pricing
%
Merchant End Rate - European traffic
%
JetPay Buy Rate - European traffic
%
Merchant End Rate - US & RoW traffic
%
JetPay End Rate - US & RoW traffic
Yes / No
Are you already a client of JetPay?
Current PSP
If, No - please key in your..
Please key in the name of the bank
Who is your current Acquiring Bank?
Yes / No
Are you leaving your Acquiring Bank?
Text here...
If Yes - please key in the reason below
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