high risk merchant accounts, high risk credit card processing, & offshore merchant accounts are our specialty!High Risk Merchant Account Application

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Merchant-Account-High-Risk.Com Application Form

If you would like to be contacted in person, please just fill out the required information section. If you would like to apply online then please complete the entire form. All the information will be kept strictly confidential and will only be shared with our acquiring bank for merchant account approval.

If you have any questions feel free to call us at (888) 875-2785 and request extension 12-IWBC
If you prefer to fax in your applications, call us for the current fax number.

Required Information

* Principal Name

* Business Phone

* Email Address

Are you interested in a hosting service?

  Basic Service - simple web site
  e-commerce-to-fax Service
  e-commerce into Bank Account Service

Personal Information

Principal's Title
Percent Ownership
Home Address
State  Zip
Home Phone
Date of Birth m d y
Social Security Number
Drivers License Number
Drivers License State
Expiration Date m d y

Business Information

Legal Business Name
Location Address
State    Zip
Merchant Site: Own Rent
If Rent:
Landlord's Name
Phone Number
Web Site Address
Business Fax

Please Check which products and services you are interested in:

Physical Terminal
Mobile Unit
Merchant Account Only

If merchant account only,
what terminal do you plan to use:

Business Type: Corporation, LLC, etc

Description of Products Sold:

Federal Tax ID#
Years in Business
Bank Name
Checking Account #
Bank Phone
Bank Contact
Business Reference #1
Contact Person #1
Phone Number #1
Business Reference #2
Contact Person #2
Phone Number #2
Average Ticket Amount
Highest Ticket Amount

Marketing Method

Percent Mix (must equal 100)
Please do not include the % symbol

% Retail
% Mail Order
% Trade Show
% Service
% Internet
% Other

Do you currently accept Visa or Mastercard?
  Yes   No

If no, expected monthly credit card volume

How did you hear about us?

Comments or Messages