Payment Gateway

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Name of Entity (Legal Name)

City

State / Province

Telephone # (Landline)

Business Site URL

Corporate / Billing Address

Country

Postal Code

Email ID:

How Long in Present Business? (Years / Months)

Authorised Contact Name

Visa/Mastercards

Card Swipe

E-Commerce

Average Ticket

VISA / DISCOVER / MASTERCARD Monthly Volume

Amex

AMEX Monthly Volume

High Ticket

AMEX Average Ticket

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MO/TO QUESTIONNAIRE

1.What percentage of sales are to: Business Clients?

Individual Consumer?

2.Method of Marketing

Other

3.Ecommerce Merchants - % of customer base:

%US

%Canada

%Other

4. Visa/Mastercard/Discover card sales are charged to the card on:

if Other (Specify):

5. Do you require deposits?

If yes, % of total sales:

OR Flat fee:

Is Final payment due before fulfillment?

If yes, how many days before final delivery?

6. Does any of your billing or marketing strategy involve negative response, or automatic billing?

If yes, explain:

7. Do you offer a product/Service Warranty or Guarantees?

If yes, is it

8. If Refund, is it:

Other

9. Does your business charge recurring billing to customers?

10. Does your business offer up-sells?

If yes, please provide the company names associated with the up-sells:

11. How is the card payment information entered into the payment system?

Other.

12. If credit card payment information is taken over the Internet is payment channel encrypted by SSL or better?

13. Do you own the product/inventory?

Is the product stored at your business location?

If No, where is it stored?

14. Who ships the product?

Contact Name:

Phone Number

Zip

Plus4

City

State

Street Number

Street Name

Unit Designator

Unit/Suite/Apt/Floor

15. Method of Delivery

If Other:

16. How long after payment is product delivered?% of Sales in Same Day

% of Sales in 1-3 Days

% of Sales in 4-7 Days

% of Sales in 8-14 Days

% of Sales in 15-30 Days

% of Sales in 30+ Days

Merchant Certificate #

Certificate Issuer

Expiry Date