Thank you for considering WorldPay and our Affiliate Partner for your Internet payment solution. This form will allow us to undertake a rapid business assessment of your company as a potential customer of WorldPay using our systems. The form is secure, and any information that you provide will only be used for the purposes of assessing your application.

Part of our acceptance procedure involves a credit check and we ask you to complete this form fully, so that we can carry this out. If you cannot answer any of the following questions, your application will be delayed and may be rejected. If you require any assistance in completing this form, please contact us at

Questions marked in bold are mandatory.

At any stage during the process, you can bookmark the form and return to it later to complete your application.
(Note: with some browsers, you may need to "reload" after using the bookmark)

Application Form
Company Name:
What is the name you trade under:
Business Contact name:
Contact email address:
We'll use this email address to send you your password and other important information.
Please confirm email address:
Telephone number:
Fax number:
Where is your company based?
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