Business Information

To set up your account appropriately, we require that you provide us with specific details about your business. This information will remain on file in our accounting offices and will serve as part of the identification for your account.

Please Note: The Business Name you enter below should be the legal name of your company. The name you provide will appear on your CCBill join forms and is also used for Card Association registration purposes, and will be presented as your business descriptor on your online customer’s monthly credit card statements. This name should be consistent with all processing requests.

Additionally, you will be required to provide a form of identification for both the Business Name and the Principal Name that you list on this application. Please ensure that the Business Name and Principal Name that you enter in the fields below match the identification EXACTLY. Failure to do so may result in the rejection of your application.

Business Name:	*
Address Line 1:	*
Address Line 2:
City:	*
State:	Select Alabama Alaska Arizona Arkansas Armed Forces Americas Armed Forces Other (AE) Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon *
ZIP or Postal Code:	*
Country:	Select United States Canada *
Business Type:	Select Corporation Sole Proprietor LLC Partnership
Are you offering any products that are stored, delivered, and used in electronic format?	Select No Yes *
Are you offering a product containing adult material or a dating website?	Select Adult Material Dating Website Both Adult & Dating Neither *
Are you shipping / mailing any product to your customer?	Select No Yes *
Estimated Annual Sales (in USD):	*
	IMPORTANT: Prior to activation you will be required to provide proof of your primary and secondary ID. * Tax information that is entered will be used for reporting purposes to the IRS.

Primary ID

Copies of the above ID's are required to complete your contract.

Please note: If you plan on offering Visa processing for this account, VISA requires that your business is based within the country you provided for your business identification. You must provide one piece of business identification and one piece of principal identification. Both types of identification must be issued by the government of your business's country.

Card associations require all transactions processed by CCBill to contain their proper e-commerce indicator. If our services are to be used for any adult digital downloadable entertainment, you must apply as a high risk client. All other applications should choose the appropriate category for which they are applying. CCBill will automatically terminate any contracts for clients that misrepresent their business.

Please be aware that these categories may require additional information from you before the setup can begin.

Principal Information

As a part of our account review process we require the contact information of the principal or primary business decision maker. This information will be used for all primary communications regarding your account and will remain on file in our system.

If electing to process VISA transactions, this information will also be used by CCBill for your VISA registration information.

Please note: Once your account is activated any change to the below information will require a written request signed by you and approved by our Accounting Department.

First Name:	*
Last Name:	*
Phone Number:	*
Fax Number:
Email:	*
	IMPORTANT: This will be the primary email address where all correspondence and confirmations regarding your account will be sent.
Alternate Email:
Address Line 1:	*
Address Line 2:
City:	*
State:	Select Alabama Alaska Arizona Arkansas Armed Forces Americas Armed Forces Other (AE) Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon *
ZIP or Postal Code:	*
Country:	Select United States Canada *