High Risk Buddy - Quick Pre-Application

Merchant Type

What is your product or service? *

Please specify your product/service:

Is this an ecommerce business?

Yes No

Do you use a fulfillment center for products? *

Yes No

Fulfillment center name: Fulfillment center phone: Are sales seasonal?

Yes No

Merchant Information

DBA Name *

Business Website

Contact First Name *

Contact Last Name *

Contact Phone # *

Business Phone # *

Email Address *

Physical Address *

City *

State *

ZIP Code *

Type of sales (must equal 100%) *

Swiped %

Keyed %

MOTO %

Ecommerce %

Total: 0%

Years in Business *

Legal Information

Legal Business Name *

Entity Type *

Tax ID (EIN) *

How many years has the business been owned? *

Owner Information

Primary Owner

First Name *

Last Name *

Ownership % *

Title *

Social Security # *

Driver's License # *

License State *

Home Street Address *

City *

State *

ZIP *

Home Phone # *

Rent or Own *

Rent Own

How many years/months at this address? *

Banking Information

Required for all applications

Bank Name *

Account Number *

Routing Number *

Processing Volume Information

Monthly Volume *

High Ticket Amount *

Average Ticket Amount *

Expected AMEX Volume (%) *

What gateway will you be using? *

Please specify gateway:

What percentage of sales are to:

Businesses %

Individual Consumers %

Total: 0%

Method of Marketing (check all that apply):

Newspaper/Magazine Television/Radio Internet Direct Mail, Brochure and/or Catalog Outbound Telemarketing Sales Other

Who processes the order? *

Merchant Fulfillment Center Other

Do you own the product/Inventory? *

Yes No

Is the product stored at your business location? *

Yes No

If No, where is it stored?

After charge authorization, how long until product ships? (days) *

I certify that all information provided is true and accurate. I authorize High Risk Buddy to verify this information and perform credit checks as necessary for underwriting purposes.

Clear form

Thanks for Your Interest!

Merchant Type

Merchant Information

Legal Information

Owner Information

Primary Owner

Banking Information

Processing Volume Information

Application Submitted Successfully!