You are visiting us today from IP ADDRESS: 22.214.171.124
ATTENTION: Supporting documentation must be ready for submittal. (articles of incorporation, or personal information and must match payment method).
Personal Information :
Date of Birth mm/dd/yy
Phone Numbers: IMPORTANT - YOU WILL RECEIVE A TELEPHONE CALL TO COMPLETE THIS PURCHASE
Do not enter leading zeros for country codes or area code portions of the phone number.
The first field is for the Country Code, not the Area Code!
FOR USA: COUNTRY CODE = 1
Enter the Area Code and Phone Number together in the second field.
Area Code & Phone No.
PinPay Account Set-up Fee $135.00* - limited time only. EUROPEAN PRICE (with PAY BY IBAN TRANSFER) €110.00*
*Other monthly and per transaction fees apply and are charged separately.
I choose to pay by Check (USA only)
USA Accounts with actual checks only can be used. Help
Your Name on Account
Bank Street Address
(Bank City, State and Zip not required.)
(No Spaces or Dashes)
(No Spaces or Dashes)
I choose to pay by Credit Card - (VISA or MASTERCARD)
Name on Card
Type of Card
Credit Card Number
Expiration Date (mm/yy)
"Virtual" credit cards are NOT acceptable. You may be asked to provide a scan/copy of your credit card before this order will be processed. Fraudulent credit card orders will result in immediate suspension of the account. Fraudulent transactions are reported.
I choose to pay by IBAN Transfer (EURO Zone only)
I choose to pay by e-gold (US$ in gold only)
Name on Account
All fields are required and must be filled in to process this application. Incorrect or missing
information will delay the processing of your order. Please make sure your personal information is
correct. Please read sign and fax the Merchant Agreement (pdf link).
The information submitted will never be sold to or made available to third parties. We will use this
information to process your application and maintain a relationship with you. Our staff is available for
phone support between the hours of 8 AM to 5 PM PST, M-F 1.602.283.5894
By checking this box I agree to all terms and conditions
of this application, I have read the Merchant Agreement, I am of Legal Age in my country of
residence and certify that I am applying for this product for my personal use and will abide by all
national and international laws and regulations that pertain to the use of this product. I hereby
certify that I am the person identified in this application.