Adult Card Processing - Experts in Credit Card Processing for High Risk Merchants

Merchant Application Worksheet

Thank you for your interest in obtaining a billing solution for your high-risk business. As mentioned on our home page we offer outstanding credit card processing service options through our processing relationships throughout the world so that you will receive the best program for your particular business. By completing the worksheet below we can provide your information to our referral partners and then they will contact you within 24 hours to offer you their best pricing for you and provide you with their original application to begin the underwriting process. At that time they will discuss with you any additional information or documentation that their processing bank requires.

This form is a worksheet so that we can better understand your processing needs and is not a formal application. All information is held in the strictest confidence.

It should take you about 5 minutes to complete this form. Please begin.

Company Information

Legal Name
Doing Business As Name (DBA)
Address Line 1
Address Line 2
State Zipcode


Business Number (Including Area Code)
Fax Number (Including Area Code)
Cell Number

Your E-mail Address

Contact Person

First Name
Last Name

Website Information

Please provide all of the websites you plan to use for your new merchant account. If more than 3 sites please provide the details separately.

Website 1
Website 2
Website 3

If any of the public pages of your website are restricted please provide the User Name and Password.

Business Profile

Please provide a brief description of your business

Time in Business Years Months or New

Ownership Type

Estimated Monthly MC/VISA Volume

Monthly Volume $
Average Ticket $
Highest Ticket $

Have you ever processed credit cards before? Yes No

If currently processing please explain the reason you are seeking a new merchant account:

Please email your last 3 months processing statements to or fax to 215-489-7880.

Questions or Comments:

All information is held in strictest confidence. Thank You.

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