TriDomainHostGateway

Online Payment Gateway Application Form

Applicant's Name First Last
Email
Phone
Web Site
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Are You an Agent or Principal Agent Principal
You are an agent if you are filling this form on behalf of someone else (Principal) , who is the owner of the website or whose bank account the online sales is going into. A web developer building an ecommerce site for a principal is an agent.
Principal' Name First Last
Company Name
Email
Phone
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Bank Information
Bank Name
Bank Account Number
Bank Account Holder's Name
Please provide the following 1. Proof of identification with International Passprt, National ID or Drivers License
2. Proof of address with either a utility bill or bank statement showing matching address
3. The file to be uploaded must be in jpg,png,or gif format and it must not be more than 1MB
Upload Proof of ID (Scanned Copy)
Upload Proof of Address (Scanned Copy)
Authentication
Date / MM / DD YYYY
I certify that all information above are true and I agree to the terms of service of service
Are You Human? Please Enter the context in the box below
Form is Property of TriDomainHostGateway.com
A Unit of Tritech Computers Ltd.
29 Adeniyi Jones Avenue, Ikeja, Lagos
Tel: 234-1-7391778, 07029463092