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Gateway Service Application Form

Company Information  
Company Name:  
Type of Business:  
Since:  
Trade Name: (if different from above)  
Description of Goods and Services that you provide  
   
Company Structure: Limited Partnership Proprietorship
Jurisdiction Company is Registered: State/Prov Country
Registration No.:  
Business Street Address:  
City:  
State/Province:  
Zip/Postal Code:  
Country:  
   
Web Site:  
   
Billing Currency: USD CDN Both
   
Contact Name:  
Phone:  
Fax:  
Email:  
   
Card Information  

Card Type Merchant Number Disc. Rate Merchant Account
Issued By
Funds to be deposited to
Institution Transit # Account #
M/C %
Visa %
US M/C %
US Visa %
AMEX %
US AMEX %
 
Other Card Type
%
Other US Card Type
%

Include a Void Cheque in your fax for each Account where funds are to be deposited.

 
Service Packages
  Setup Fee Monthly Fee Transaction Fee
1A $150 $35 $0.50
1B $250 $45 $0.25
1C  $300 $75 $0.15
1D  $400 $295 $0.10
2nd Currency $150 $15 N/A
 
Please enter the description to appear on your Customers' Credit Card Statements (Maximum of 20 characters).

 
Please note that this description will appear in UPPER CASE.

 
Authorized by:
Name:  
Position:  
2nd Name: (if necessary)  
Position:  
 
 
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