Merchant Processing Assessment

Thank you for considering Liberty Enterprises for your Internet Verified Payment Solution. This form will allow us to undertake a rapid business assessment of your company as a potential customer. All information is completely secure and will only be used for the purposes of assessing your application.  

Fields marked with a (*) are required.

Contact Information

Date:
Incorporation Name: *
Location of Incorporation: *
Business Type (E-commerce, Pharmaceutical, etc.): *
Main Web Address: *
Contact Person: *
Contact Person Title:
Contact Telephone Number:
(Please ensure you include the area code and that your number is correct) 		*
Customer Support Telephone Number:
Time Zone:
Hours of Contact:
Contact Email Address: *
Launch Date:
Desired Password: *

Additional Merchant Websites

Web Site URL:
Web Site Url:
Web Site Url:
Web Site Url:

Transaction Information
Are you processing with a third party? Yes No
Have you ever processed with a third party before? Yes No
If so, which company have you processed with?
For how long have you been processing with them?
(Expected) Number of Monthly Transactions:
(Expected) Monthly Amount Processed:
Maximum Single Transaction:
Average Charge Amount:
Total Credit Card Sales Volume for the Last 12 Months:
Expected Percentage of Credit Cards by Phone:
Expected Percentage of Credit Cards by Internet:
Total Number of Chargebacks:
Total Amount of Chargebacks:

Other Information
Please explain how you intend to market your website:
Where Did You Hear About Us:
(This will help us accommodate you accordingly.)
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