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PLEASE COMPLETE ALL REQUIRED FIELDS AND SEND IT BY
FAX OR SECURE INTERNET
Thetabiz Corporation provides access to credit card acceptance as
intermediary. We require our clients to complete this form for the offshore
based merchant account.
MERCHANT APPLICATION FORM (Offshore Account)
COMPANY INFORMATION
Trading Name
Merchant Name
Type of Business or
Industry
URL’s
Address
Telephone
Fax
E-mail
Registration Date
Country
Registration No.
COMPANY CONTACTS
CORPORATE
CONTACT
TECHNICAL
CONTACT
CEO Name
Name
Passport /Country
Telephone
Address
Fax
E-mail
E-mail
Telephone
DIRECTORS
FINANCIAL
OFFICER
Name
Name
Passport No.
Telephone
E-mail
Fax
Name
E-mail
Passport No.
CUSTOMER
SUPPORT
E-mail
Telephone
Name
E-Mail
Passport No.
Fax
E-Mail
SHAREHOLDERS'
OR OWNERS'
NAMES
AUTHORIZED
SIGNATORY
Name
Address
Passport No.
Name
Address
Passport No.
BUSINESS MODEL
Please describe business model:
URL REQUIREMENTS AND SPECIFICATION
If you are a Casino/Sports Book, do you have a valid
license?
YES
□
NO □
If you are a Pharmacy, are you legally registered and
meet FDA regulations?
YES
□
NO □
Company is identifiable at any time to cardholders YES
□
NO □
Cardholder is asked for address and phone number YES
□
NO □
All products comply to the same MCC code YES
□
NO □
CVV2 compulsory YES
□
NO □
Transaction currency YES
□
NO □
Privacy Policy YES
□
NO □
Return and refund policy YES
□
NO □
SSL Certified YES
□
NO □
Appearance of Descriptor on statement YES
□
NO □
Display of VISA and MC logos YES
□
NO □
Clear display of prices and fees YES
□
NO □
Debiting time of cardholder YES
□
NO □
Shipping Policy YES
□
NO □
Fulfillment Policy YES
□
NO □
Notes regarding jurisdiction and cardholder’s
responsibility
YES
□
NO □
Note regarding legal age of 18+ if applicable to your site YES
□
NO □
Do you use XML/HTTP Redirect solution for gateway
integration? What programming language do you use?
Please give details:
Are you listed on MATCH?
BANK ACCOUNT INFORMATION
GENERAL
DETAILS
BANK DETAILS
Bank Name
Account No.
Beneficiary
Name
Swift Code
Full Address
ABA No.
Contact Person
Routing No.
Telephone
Fax
E-Mail
PROCESSING INFORMATION
TRANSACTIONS
PROCESSING
HISTORY
Monthly
Transactions
Previous
Processing?
Total Sales per
Month
Former Processors
Average Ticket
(sale)
Period of
Processing
Type of
Transaction
Batch/Online
Reason for leaving
PAYMENT
INFORMATION
Currencies
Other payment
methods
Transaction
currency
Settlement
Currency
Are
good/services
based
on signed orders?
Yes □ No □
Do you have
credit limit
policy in case of
casino?
Yes □ No □
Details
Detail Fraud
tools
PROCESSING HISTORY
VISA
Details
Last
Month
2
Months
ago
3
Months
ago
4
Months
ago
5
Months
ago
6
Months
ago
Sales Volume
No. Transactions
Volume
Chargeback
No. of
Chargeback
Chargeback
Volume Ratio
Chargeback
Ratio by Count
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