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Merchant Name *

Full Name

Target Vertical(s) *

Target Market(s) (List ALL countries desired) *

Please estimate the Target Markets by % of each region *

Country where the Merchant is domiciled/located *

Do you have any licenses? If so please list *

Settlement currency type (Which FIAT or Crypto or Both) *

Nationality of the Authorized Signatory *

Payment method(s) requested (PAY-IN) *

If Credit Cards, are Merchants Whitelisting or seeking FTD (First Time Deposit)? *

Is a PAY-OUT (Disbursement) solution required? *

Minimum transaction amount

Maximum transaction amount *

Current Total Monthly Volume *

Forecasted Monthly Volume in 6 Months *

Do you have any previous credit card processing history *

Are you actively accepting payments and what is the method(s)? *

Has your account ever been closed while accepting credit card? (MATCH) *

URL Address(es) *

Email *

Phone

Payjeezy Agent Name

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