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Merchant Sign-up
To apply for a Merchant Account,
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Merchant Registration Form
Company Information
Legal Name:
* Legal Name is required.
Registered address:
* Registered Address is required.
DBA/Trade Name:
* DBA/Trade Name is required.
Phone No.:
Fax No.:
Mobile No.:
Email Address:
* Phone Number is required.
Invalid format.
* Fax Number is required.
Invalid format.
* Mobile Number is required.
Invalid format.
* Email Address is required.
Invalid format.
Company Registration No.:
Tax Identification No.:
Single Proprietorship
Partnership/Corporation
With tax
Tax Exempt
Company Director Information (Beneficial Owner)
Full Name:
* Full Name is required.
Designation:
* Designation is required.
Address:
* Address is required.
Birth date:
* Birth Date is required.
* Follow this format "mm/dd/yy".
Telephone No.:
* Telephone Number is required.
Invalid format.
Email Address:
* Email Address is required.
Invalid format.
E.g name@company.com
Primary Contact Person
Full Name:
* Full Name is required.
Designation:
* Designation is required.
Telephone No.:
* Telephone Number is required.
Invalid format.
Email Address:
* Email Address is required.
Invalid format.
E.g name@company.com
Financial Contact Person
Full Name:
* Full Name is required.
Designation:
* Designation is required.
Telephone No.:
* Telephone Number is required.
Invalid format.
Email Address:
* Email Address is required.
Invalid format.
E.g name@company.com
Authorized Signatory (this person is the one to sign the agreement)
Full Name:
* Full Name is required.
Designation:
* Designation is required.
Address:
* Address is required.
Birth date:
* Birth Date is required.
* Follow this format "mm/dd/yy".
Telephone No.:
* Telephone Number is required.
Invalid format.
Email Address:
* Email Address is required.
Invalid format.
E.g name@company.com
Technical Contact Person
Full Name:
* Full Name is required.
Designation:
* Designation is required.
Telephone No.:
* Telephone Number is required.
Invalid format.
Email Address:
* Email Address is required.
Invalid format.
E.g name@company.com
Company Website/Shop URL
IP Address
* Email Address is required.
Invalid format.
E.g http://xxx.xxx.xxx
https://xxx.xxx.xxx
ftp://xxx.xxx.xxx.
* This field is required.
Invalid format.
Validates IPv4, IPv6, or both kinds of IP addresses.
Security Code:
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