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This form is to be used only by those businesses with an address in either Canada or the United States.

Corporate Infomation: * is required
Company DBA Name:*
Company Legal Name:*
Company GST Number: (Optional Requirement for Canadian Applications Only)
URL:*
Address:*
City:* Prov/State:*
Country:* Postal/Zip Code:*
Phone:* () - - EXT: Fax: () - -
Select Your Company Type:* If Other Please Specify:
Years In Business:*
Best Time To Contact Merchant:
Average Sale/Ticket:*
Annual Credit Card Sales:*
 
Account Contacts:
Primary Contact:
Contact Name:*
Email:*
Address Same as Above:
Phone:* () - - EXT:
Address:*
City:* Prov/State:*
Country:* Postal/Zip Code:*
Secondary Contact:
Contact Name:*
Email:*
Address Same as Above:
Phone:* () - - EXT:
Address:*
City:* Prov/State:*
Country:* Postal Code:*
 
Login Information:
User Name (6 - 15 Characters):*
Password (6 - 15 Characters):*
ReEnter Password (6 - 15 Characters):*
 
Security Questions:
These are required to protect your private information in the event you need to recover your password or are requesting information regarding your account when speaking with one of our staff members. When contacting our staff, you will be required to provide responses to your questions and/or specific information about your account to verify who you are. It is best to pick questions that only you will remember.
 
Question 1
Select a Question:*
If Custom Specify:
Answer:*
Question 2
Select a Question:*
If Custom Specify:
Answer:*
Question 3
Select a Question:*
If Custom Specify:
Answer:*
Are you and Existing Merchant:* Yes No
To prevent abuse of this registration form , we require you to enter the two words in the Captcha box prior to submitting your merchant application.
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