Payment Processing Request
SECTION 1. BUSINESS INFORMATION
Client’s Business Name: *
Alpha, LLC
Country of business incorporation: *
USA
Client’s web-site: *
Business Address: *
Business started: *
MM
/
DD
/
YYYY
Business Phone #: *
+1 234 567 8900
Business Email: *
Preferred messenger for contact (Telegram, Skype and etc): *
Telegram @myusername
CEO (Manager)
Full Name *
John Smith
DOB: *
MM
/
DD
/
YYYY
Title: *
CEO
Bank Account for Withdrawal
Can provide later
Name of the bank:
Bank of America
Country:
USA
SWIFT (Routing #):
123456
Account #:
123456789
SECTION 2. BUSINESS AND PROCESSING INFORMATION
What do you sell? *
Servers
How do you accept payments now? *
Via Stripe
Monthly revenue for the last 6 months in $ *
12345
Planned monthly revenue in $: *
34567
The Minimum Ticket $: *
50
The largest Ticket $: *
500
The Average Ticket $: *
300
Monthly Transaction Count: *
10000
Recurring Billing? *
MONTHLY CHARGEBACK AND REFUND DATA
Chargeback Count for the last 6 months: *
Average chargeback amount for the last 6 months: *
Chargeback % for the last 6 months: *
Refund Count for the last 6 months: *
Average Refund amount for the last 6 months *
Refund % for the last 6 months: *
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