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Please complete all fields to ensure that there is no delay to your application If you have any questions do not hesitate to contact us.
Company Information
Company Information
Processing
Integration
Shareholders
The person completing this application and liaising with the QUAYPAY sales team
First Name
Last Name
Job Title
Work Email Address
Work Telephone Number
Mobile/Cell Phone Number
Company Information
Processing
Integration
Shareholders
Company Name
Company Type
Website Address
Company Address
Building Number or Name
Street Name
City
Province
Postal Code
Country
Operational Address
Main Telephone
Incorporation Number
Date of Incorporation
Industry
VAT/Tax Number
Company Information
Processing
Integration
Shareholders
Please list any individual or companies holding 25% or more equity in the company registering. Use the + button to add a new shareholder.
First Name
Last Name
Percentage of Shares
Company Position
Date of Birth
Nationality
Home Address – Building Name or Number
Home Address – Street Name
Home Address – City
Home Address – Province
Home Address – Postal Code
Home Address – Country
Company Information
Processing
Integration
Shareholders
Please view USER RIGHTS ROLE on the last page of this application as this details user types
First Name
Last Name
Date of Birth
Company Position
Work Email Address
Work Tel Number
Home Address – Building Name or Number
Home Address – Street Name
Home Address – City
Home Address – Province
Home Address – Postal Code
Home Address – Country
User Type
Company Information
Processing
Integration
URLs
Information
Use the + button to add a new currency account (max 3). If needed, supply additional currency accounts on company letterhead signed by a Director.
Account Currency 1
Name of Account Holder
Bank Name
Country of Account
Account Number or IBAN
BIC or Sort Code
Company Information
Processing
Integration
URLs
Information
Use the + button to add a new URL
Company Information
Processing
Integration
URLs
Information
Settlement Currency
Cards you wish to accept
Current Acquiring Bank
Lenght of time with Acquirer
Reason for leaving
If you’ve ever had a processing relationship terminated – please comment on the reasons
Enter reasons here
Average Transaction Value
High Volume Months
Chargeback to Sale Ratio
Amount Processed /Month
No of Chargebacks /Month
Refunds to Sale Ratio
No of Transactions /Month
No of Refunds /Month
Business Cards Turnover (%)
Service Required
If POS required, Number of Terminals
No
Geographic location of cardholders (%)
Domestic (cards located in your country)
%
Intra-Regional (cards from your continent)
%
Inter-Regional (cards from rest of world)
%
Delivery / Spend Lead Times (how long after placing an order does it take for the receipt of goods or service)
0 > 3 days
%
4 > 7 days
%
8 > 14 days
%
15 > 30 days
%
30 days +
%
PCI DSS Compliance
Domestic (cards located in your country)
License
Are you required to be Licensed
If Yes, please provide details on the licence held
Company Information
Processing
Integration
Contact
Type
The person completing this application and liaising with the QUAYPAY integration team
First Name
Last Name
Job Title
Work Email Address
Work Telephone Number
Mobile/Cell Phone Number
Company Information
Processing
Integration
Contact
Type
If ticked, please select from dropdown
If ticked, please select from dropdown
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