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Information required to complete Application for Merchant Facilities
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Business Details
(Please complete the relevant sections and press "Send" when you are done)
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Trading Name
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ARBN |
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Company Name (only PTY LTD) |
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ACN |
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Contact Name & Position |
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ABN |
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Buisness Phone |
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Fax |
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Eftpos Phone |
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Mobile No. |
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Email |
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Trading Address |
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Suburb/City |
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Postcode |
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Mailing Address |
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Suburb/City |
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Postcode |
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Settlement Account Details
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Bank Account Name (As appears on your checkbook) |
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Bank |
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Branch |
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BSB |
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Account No. |
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Time with current bank |
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ILMCOA No. |
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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.
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Name |
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Position |
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Date |
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