Payment Processing Application Form

Payment Processing Application Form

The information provided in this form will be used solely for the intent to provide pricing on the products you are interested in. Information provided to InterCash will not be made available to any third party.

Company Name Website URL:
Address:    
County/Region: Contact Name:
Country: Title:  
City: Email:
Postal Code:    
Telephone:    
Fax:    
Mobile:    
       

Business Description / Activities

Please provide a detailed description of your business’ nature and activities:
       
Purpose of Payment Services:
Payroll Refund Bonus Commission
Loyalty Gaming Supplier Payment Affiliate Compensation
Other (Describe)  
       
Product Selection & Fee Schedule
Please complete this section in order to receive your custom fee structure per product requested

Check

Monthly Transactions

Average ticket
  USD$

#

$

  CAD$

#

$

  EUR€

#

€

  GBP£

#

£

EFT

Monthly Transactions

Average ticket

  USD$ (ACH)

#

$

   CAD$ (EFT)

#

$

  EUR€ (ESP)

#

€

International Money Transfer*

Monthly Transactions

Average ticket

  USD$

#

$

       
*MoneyGram International Cash Refunds are issued in USD and picked up by recipient in local currency

Technical Details

Require webservice integration

Require batch integration

IT Contact Name:

Email:

Telephone:

 
 
Your Name:  

 

 
Please enter the following code:
  
Following the receipt of this application, InterCash will provide a Merchant Agreement, your custom fee structure, as well as Due Diligence forms to be signed and completed in order to move forward with your setup for our services.
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