Payment Gateway Register Form for Privilege 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)

: Rs

Average cost of unit sold *
(in INR)

: Rs

Number of transactions *

: No per Month
Logistics Partner Details *
(Details of how and through what mode you will deliver your Products/ Services.)
:




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