Symentech

Payment Gateway Register Form for Premium Account

Contact Person's Name *

Business Filing Status *

Address *
(Do not include Country)

City *

State *

Zip/Postal code *

Country *

Phone No. *

(For Southern Symentech & Solutions use only.

Country Code

Area Code

Phone Number

We do not display your phone number to customer.)

Fax No.

(For Southern Symentech & Solutions use only. We do not display this number to customer.)

Email *

Website Details

Website Name (URL) *

[ Ex- www.symentech.com ]

Account Type *

Bank Details

Pay To *

This name will appear on our payment cheques issued by us to you.

Account Number *

Bank Account Type *

Bank Name *

Branch Name *

Branch City *

IFSC code *

Additional Details

Owners/Promoters *
(Names, Age, Sex, EducationalQualifications, Residential Address and Financial Stake)

Angel / VC funding details *
( If Any )

Brief Description

Brief Description about your Company & Site *

Product Description *
About Products & Services you intend to sell using our Payment Gateway

Minimum cost of unit sold *
(in INR)

Average cost of unit sold *
(in INR)

Number of transactions *

No per Month

Logistics Partner Details *
(Details of how and through what mode you will deliver your Products/ Services.)