Application Form

Here you will find a merchant questionnaire so that we can get to know a little about your business and refer you to services which can meet its needs. If you have particular needs that aren’t met with this form please feel free to contact us directly.

Note: Items marked with an asterisk(*) are required.

Contact Name*

Contact Email*


Company Name*

DBA / Trading Name

Company Street Address*

Company City, State, Zip, Country*

Country of Incorporation*


Detailed description of products or services*

Web Site URL(s)*

Test Username

Test Password

Customer Support Number*

Customer Support Email*

Method of Acceptance (must equal 100%)*
% Web / online sales
% MOTO / call center
% Swipe / POS or Other

Target Markets (must equal 100%)*
% USA
% Europe
% Asia
% Latin America
% Other


Complete the following for Credit Card Acceptance

Is this business currently accepting credit cards?  yes no

If you answered "yes" above, please complete the following:

How long have you been accepting credit cards?

Current Payment Service Provider(s)

Reason for Change

I can provide 6 months processing statements:  yes no

Please include currencies for the numbers below. If you are a startup please use projected figures for the items below.

Monthly Credit Card Volume

Average Transaction Value

Highest Transaction Value

Chargeback Ratio


Complete the following for eCheck Acceptance

Is this business currently accepting eChecks/ACH?  yes no

If you answered "yes" above, please complete the following:

How long have you been accepting eChecks/ACH?

Current Payment Service Provider(s)

Reason for Change

I can provide eCheck/ACH processing statements:  yes no

Please include currencies for the numbers below. If you are a startup please use projected figures for the items below.

Monthly eCheck/ACH Volume

Average Transaction Value

Highest Transaction Value

Return Ratio


Owner Name*

Owner Street Address*

Owner City, State, Zip, Country*

Owner Email*

Owner Telephone Number*


How did you find Pioneer Payments?
If you chose Agent referral, please enter name of Agent: