Information required to complete Application for Merchant Facilities


Business Details

(Please complete the relevant sections and press "Send" when you are done)

Trading Name

ARBN

   

Company Name (only PTY LTD)

ACN

   

Contact Name & Position

ABN

   

Buisness Phone

Fax

Eftpos Phone

Mobile No.

Email

   

Trading Address

Suburb/City

Postcode

   
   

Mailing Address

Suburb/City

Postcode

Settlement Account Details

Bank Account Name (As appears on your checkbook)

Bank

Branch

BSB

Account No.

Time with current bank

ILMCOA No.

   
I am an authorised representative of the above business and hereby authorise Ezepos to act on our behalf in reference to our merchant facilities including, but not limited to, negotiation of fees and charges. I agree not to contact our current merchant facility provider or any other merchant facility provider in relation to negotiating fees and charges for the said business merchant facility unless instructed by Ezepos.

Name

Position

Date

   

 
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