Application Form

50%

Contact Information

Business Information

Online Gambling, Financial Services, Pharmaceuticals, etc.

Does your business require a license?

Yes

No

Business Location

Same Like Registered

Business Principals

Please list all Company Directors. If Director is legal entity please state Company Name.

Additional Business Principals

Business Owners

Please list all Company Owners with more than 25% share. If Owner is legal
entity please state Company Name.

Same Like Registered

Additional Business Owners

Ultimate Beneficial Owners

If different than Business Owner, please list all Ultimate Company Owners
with more than 25% share

Same Like Registered

Additional Ultimate Beneficial Owners

Website Information

Are you the website domain owner?

Yes

No

Additional Website Information

Processing Information

  • Expected Target Markets:

  • Required Processing Currencies:

  • Required Settlement Currencies:

  • Required Terminal Types:

  • PCI DSS Compliant:

Bank Account Information

I don’t have a bank account. I need one

I have read and accept Terms of Use & Privacy Policy