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MERCHANT REGISTRATION FORM

1. Corporate Identity:
Corporate Name:
Doing Business As (if applicable):
Web site address:
Activity of the company:
Activity Code:
Headquarters / Billing Address (No postal Boxes)
City:
Zip:
State:
Country:
Company Information
Company is only Internet based:
Years Operating:
Central Phone Number:
Fax Number:
Primary Company Contact Officer
Name / Position:
E-mail Address
Office Phone Number:
Home Address of Primary Contact Officer
Home Phone:
Cellular Phone:



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