Agent Count Reg

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Agent Registration

Credential Information

First_Name

Last_Name

User_Email Your email will not ever be shared!!

Phone_Number

Password ( at least 8 characters )

Confirm Password

Company information:

Company Name

Company Address

City

State / Province

Zip Code/Post Code

Company Country

Company Web URL

Company Product

Company Product Description

Customer Service Information:

Support Contact Full Name

Customer support email

Customer support phone

Owner / Manager Information:

Owner's Full Name

Owner's Address

City

State

Zip Code/Post code

Owner's Country

Owner's Phone

Owner's Passport/ID

Owner/Manager's Email:

Owner's Skype or Social Media

Owner's SSN/EIN

SSN/EIN Display

Processing History Information:

Do you accept credit cards

Have you ever processed before ?

Have you ever had a Merchant Account ?

Time with Processor

Former/Current Processor

Other Information:

How did you Hear About Us

Agent Name If don,t know , type No

Agent Id If don,t know Skip this field

Transaction Information:

Sales amount per Month $

Times of transaction Monthly

Max ticket Amount($) $

Min ticket Amount($) $

Transaction Description

Application Date

* Application Status

* Application Completed ?

Agreement and Service terms of Service:

I agree to the terms and conditions, Click Here to read terms and policy files.

Password must contain the following:

A lowercase letter

A capital (uppercase) letter

A number

A special character

Minimum 8 characters