High Risk Clients Form

Primary contact *

First Name

Last Name

Email *

example@example.com

Phone Number

phone number

Please provide description of your business model. *

Industry sector *

Please list the categorise your business sector. Example - Airline

Test log ins

Please provide test user and password if your URL requires you to log in, these accounts should be fully verified.

Please attached your bank statement *

License required to operate? *YesNo

Is the time before purchase and delivery over 7 days? *YesNo

Are full payments taken before delivery of product/service? *YesNo

Service requirements*

Percentage of card volume per method *e-commerce %

Point of sale %

Virtual terminal %

Pay by link %

Do you currently accept card payments? *YesNo

Transactions *Minimum Transaction *

Average Transaction *

Maximum Transaction *

Projected processing with Axcess100% of processing volume75% of processing volume50% of processing volume25% of processing volume

Processing currencies *

Settlement currencies *

Please input target countries by % *Country

Do you take recurring payments? *YesNo