Technology Vendor Registration Form

The Technology Provider Registration Form assists Visa's business and technical staff in a preliminary assessment of potential vendors.

Until a non-disclosure and/or definitive agreement is executed by both parties, neither party shall have any obligation to the other with respect to the confidentiality of the information shared in this document, or to enter into any definitive agreement or otherwise.

Please do not provide any confidential information to Visa until the terms and conditions relating to receipt and protection of such information are agreed upon in a non-disclosure or other agreement.

What happens after registration?

Once you have registered, your information will be routed to Visa's technology committee for review. If your product or service is of interest, a Visa representative will be in contact with you. Otherwise, your information will be kept on file in Visa's database for future reference.

* Indicates a required field.

Company Information

Company Name*
Company Address*
City*
State*
Zip*
Country*
Phone*
Extension
Fax*
Web Site Address*

Company Profile

Year established*
Current number of employees*
Subsidiaries and locations (If applicable)
Describe the products or services that you offer*
Please identify countries and markets where you currently do business. Include your key clients or current customer base.*
Are you currently doing business with Visa (USA), Visa International, Inovant, Vital Processing Services or any of their affiliates? (If yes, please specify.)*

Primary Contact Information

Name*
Title*
Address*
City*
State*
Zip*
Country*
Phone*
Extension
Fax*
E-mail Address*

Technology & Payment Specific Information

Please provide a brief overview of your technology solution*
Please list the clients who are currently using your technology solution*
With regard to the payment industry, which one of the following best describes your primary area of business?*
To which of the following stakeholders is the product/service targeted? (Check all that apply)*
Acquirer Processor Issuer Processor Merchant
Consumer/Cardholder Member Bank Visa
Please select one of the following within Visa with whom you would like to discuss your initiative*

Proposal

Please provide a brief overview of the general topic you would like to discuss with Visa*