Internet Payment Gateway

Internet Payment Gateway (iPG) Merchant Application

General Business Information (fields with

are required)

Company Name:

Doing Business As:

Full Name of Contact:

Title:

Street Address:

City:

State/Province:

Zip/Postal Code:

Phone:

ext:

(please include city
and country code)

Fax:

(please include city and country code)

Email:

Corp./Fed. Tax ID Number:

Identication Number/SSN:

Website Address/URL:

Sole Ownership		Partnership
Non Profit		Private Corporation

Country State Incorporated:

Month/Year Started:

No. Of Employees:

Acquiring Bank Information

Bank Name:

Contact:

Account Number:

Street Address:

Phone:

City:

State/Province:

Zip/Postal Code: