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<title>High Risk Merchant Account & Offshore Merchant Accounts - Apply Online!</title>

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				<td width="65" valign="top" style="padding-top: 5px;"><a href="high-risk-merchant-account.html"><img src="images/globe.jpg" alt="High Risk Merchant Account & Offshore Merchant Account Solutions" border="0" align="top"></a></td>
				<td width="353" style="padding-left: 10px;"><h1 class="style20"><span class="style21">High Risk</span> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;800-862-0785<br>
              <span class="style21">Merchant Account</span></span></h1></td>
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         <td align="left" valign="top" width="444" height="22"><a href="http://www.cmscreditcards.com/"><img src="images/buttons/home2.gif" border="0"></a><a href="about.html"><img src="images/buttons/about.gif" border="0"></a><a href="contact.html"><img src="images/buttons/contact.gif" border="0"></a><a href="articles.html" title="Credit Card Processing Articles"><img src="images/buttons/articles.gif" alt="Credit Card Processing Articles"></a><a href="pci-compliance.html" title="PCI Compliance"><img src="images/buttons/pci.gif" alt="PCI Compliance"></a></td>
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			<td colspan="3" align="center" style="padding-bottom: 15px;"><p><img src="images/bullet.jpg" width="15" height="15"> <a href="payment-processing.html"  class="violetSubNav">Payment Processing Solutions </a><img src="images/bullet.jpg" width="15" height="15"> <a href="business-cash-advance.html" class="violetSubNav">Business 
        Cash Advance</a> <img src="images/bullet.jpg" width="15" height="15"> <a href="merchant-account-affiliate.html"  class="violetSubNav">Merchant 
        Account Affiliate Program</a> <br>
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			<h1>Apply NOW for a High Risk Merchant Account</h1>
			<p>Online Pre-Application Questionaire: No obligation
Please fill the merchant account application below out completely. However, if there is any information that you do not have available simply leave that blank and our staff will help you to obtain the missing information when we process your application.</p>
<p>For your information and security, your account information is kept safe with the highest grade of commercially available encryption. Your information will be kept confidential and will not be shared with anyone. </p>
			<br>
	    (*)<span class="style3"> Required field</span><br>
        <br>
		<div align="center"> 
			<form name="cashAdvanceApply" method="post" enctype="multipart/form-data" action="highrisk.php">
        <input type="hidden" name="require" value="bussnumber,email">
		<input type="hidden" name="redirect" value="thankyou.html">
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              <table width="80%"  border="1" cellpadding="4" cellspacing="4" bordercolor="#602074">
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                  <td  height="20" colspan="2"><b>COMPANY INFORMATION</b></td> 
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                  <td width="35%">Owners name</td>
                  <td width="65%"> <input type="text" name="ownername" value="" /> </td>
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                  <td>Type of Ownership SP LLC CORP</td>
                  <td><input type="text" name="ownership" value=""/></td>
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                  <td>Date of Birth</td>
                  <td><input type="text" name="birthday"  value=""/></td>
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                  <td>Contact name</td>
                  <td><input type="text" name="contact" value=""/></td>
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                  <td>Legal name of business</td>
                  <td><input type="text" name="bussname" value=""/></td>
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                  <td>DBA name if different</td>
                  <td><input type="text" name="dbaname" value=""/></td>
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                  <td>Company physical address</td>
                  <td><input type="text" name="comannyadd" value=""/></td>
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                  <td colspan="2">
				  	<table   border="0" cellspacing="0" cellpadding="2">
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                        <td>City</td>
                        <td><input type="text" name="city" size="15" value=""/></td>
                        <td nowrap>&nbsp; State</td>
                        <td><input type="text" name="state" size="15" value=""/></td>
                        <td nowrap>&nbsp; Zip code</td>
                        <td><input type="text" name="zip" size="15" value=""/></td>
                      </tr>
                    </table></td>
                </tr>
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                  <td>Owner home address</td>
                  <td><input type="text" name="homeadd" value=""/></td>
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                        <td>City</td>
                        <td><input type="text" name="homecity" size="15" value=""/></td>
                        <td nowrap>&nbsp; State</td>
                        <td><input type="text" name="homestate" size="15" value=""/></td>
                        <td nowrap>&nbsp; Zip code</td>
                        <td><input type="text" name="homezip" size="15" value=""/></td>
                      </tr>
                    </table></td>
                </tr>
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                  <td>Owner home number</td>
                  <td><input type="text" name="homenumber" value=""/></td>
                </tr>
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                  <td>Cell number</td>
                  <td><input type="text" name="cellnumber" value=""/></td>
                </tr>
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                  <td>Business number  (*)</td>
                  <td><input type="text" name="bussnumber" value=""/></td>
                </tr>
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                  <td>Business fax number</td>
                  <td><input type="text" name="fax" value=""/></td>
                </tr>
              <tr>
                  <td>E-mail address (*)</td>
                  <td><input type="text" name="email" value=""/></td>
                </tr>
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                  <td>Website address</td>
                  <td><input type="text" name="webadd" value=""/></td>
                </tr>
                  <tr>
                  <td  height="20" colspan="2"><b>CREDIT CARD SALES INFORMATION</b></td> 
                </tr> 
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                  <td>What products or service are you selling?</td>
                  <td><input type="text" name="selling" value=""/></td>
                </tr>
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                  <td>Estimated monthly credit card volume</td>
                  <td><input type="text" name="ccvolume" value=""/></td>
                </tr>
               <tr>
                  <td>Estimated average sales ticket amount</td>
                  <td><input type="text" name="ticket" value=""/></td>
                </tr> 
				 <tr>
                  <td  height="20" colspan="2"><b>CREDIT CARD MACHINE OR WEBSITE SOFTWARE</b></td> 
                </tr>  
                <tr>
                  <td>Do you need a credit card machine?</td>
                  <td nowrap> 
				  				  Yes <input type="radio" name="machine" value="Yes" />&nbsp;&nbsp;&nbsp;&nbsp;
					                    No <input type="radio" name="machine" value="No" checked></td>
                </tr>
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                  <td>Do you need processing software?</td>
                  <td>  
				    				  Yes <input type="radio" name="software" value="Yes" />&nbsp;&nbsp;&nbsp;&nbsp;
					                    No <input type="radio" name="software" value="No" checked></td> 
                </tr>
               <tr>
                  <td  height="20" colspan="2"><b>COMMENTS</b></td> 
                </tr>  
                <tr>
                  <td><b>Comments / Questions</b></td>
                  <td><textarea name="comment" rows="3" COLS="30"></textarea></td>
                </tr> 
				</table>
				<table width="80%">
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                  <td>&nbsp;</td>
                  <td>&nbsp;</td>
                </tr>  
				 <tr>
                  <td colspan="2"> <font color="#FF0000">Disclosure: *** BY FEDERAL 
                    LAW ALL INFORMATION PROVIDED WILL REMAIN CONFIDENTIAL <br><br>
					Merchant applications considered high risk and/or unacceptable by our sponsor bank will be placed with an offshore bank or other third party processor.<br><br>
					Pre-Approval subject to business type restriction and credit approval</font>                  </td>
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                  <td colspan="2" align="center"><input type="hidden" name="sfh" value="1191211200">
                      <input type="submit" name="Submit" value="Submit"/>                   </td>
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