Application Form

Application form for UPG online card processing

Please complete the form below, along with your payment of £25 + VAT, and we will contact the relevant bank to request an Internet merchant number for you. Please do not contact your bank yourself as this will lead to complications and delays. If you already have an Internet merchant number please enter it in the relevant box below. If you currently have no merchant facilities at all we will contact a selection of banks and obtain quotations for you. There is no obligation for you to go ahead with the merchant account quotes.

Company details

Company Name

Company Type

Company Number (If Ltd. Company)

When did your company start trading? (to nearest month)

Company Address (No PO Boxes please)

Address line 1

Address line 2

Town/City

County

Postcode

Country

Contact Name (preferably owner/director)

Contact Email

Contact Tel (Landline)

Contact Tel (Alternative)

Contact Fax

Your web site address

Your SecureHosting account no. (If you have one)

Your projected card turnover for next 12 months

Average transaction value

Your total projected turnover for next 12 months<

Description of business activity (eg. CD Sales)

Do you belong to any trade associations? If so please enter names

Details regarding your current merchant account(s)

Do you already have a merchant account?  Yes  No

Your merchant services acquiring bank

Your merchant acccount number for offline manual card processing
(If applicable)

Internet merchant acccount number

If available. We will contact your bank to establish this for you if you do not have one.

Your bank account details for deposit of funds

Sort Code

Bank account number

Bank name

Bank address

Target live date

Payment details

There is a £25 + VAT non-refundable application fee for the UPG service. Please complete the payment details below. You will be sent a VAT invoice in the post.

Total Cost £25 + VAT (= £30.00)

Credit card type

Credit card number

Card expiry month

Card expiry year

Card start month

Card start year

Security Number (last 3 digits on magnetic strip on reverse of your card)

Card Holder's Name

Billing Details for invoice (Tick box if same as above)

Billing Company Name

Billing Address line 1

Billing Address line 2

Billing Town/City

Billing County

Billing Postcode

Billing Country

Billing Contact Name (preferably owner/director)

Any other comments?

Online card processing from as little as 8p per transaction