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MERCHANT CHANGE REQUEST FORM

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MERCHANT CHANGE REQUEST FORM Powered By Docstoc
					Global Payment Systems of Canada, Ltd. -

(Formerly NDC)

MERCHANT CHANGE REQUEST FORM

Merchant Information
Merchant Name
Doing Business As

NOTE: Please ensure the information below is the same as your
Merchant Agreements

*Please circle which service you wish to request from the list on the right side of this page*
*Max 25 characters appear under “Merchant Name” on Cardholder’s Credit Card Statement*

SERVICES REQUESTED
CHANGE NAME/ADDRESS CHANGE MERCHANT #(S) AND/OR BANKING

Current Bank ICA (If known) Merchant Address
City

0

0

Current Terminal Merchant ID

Prov./State

Postal/Zip

CHANGE POS/VAR ADD/DELETE SERVICES
OTHER:

*Max 15 characters appear under “City” on Cardholder’s Credit Card Statement*
Contact Name Telephone # Fax # Email

P.O.S. System Information
Vendor/Dealer Name: Telephone #
Communication Type DIAL UP

POS System Name: Contact Name: Fax #
IP/SSL IP VPN IP DATAWIRE OTHER

Credit Card Information
Card Types
MasterCard
ADD/CHANGE/DELETE ADD/CHANGE/DELETE

Note: Please ensure the information below is ACCURATE as it will affect your bank account deposits. Circle the companies that provided your MC & Visa merchant #

Merchant Number

GPI

Credit Union/CUETS Paymentech/ Citibank Moneris First Data
GPI

VISA

American Express
ADD/CHANGE/DELETE ADD/CHANGE/DELETE ADD/CHANGE/DELETE

Moneris
Discover Sears
ADD/DELETE

TD CanadaTrust Paymentech Desjardins

JCB

Attach a VOID Cheque from both MC and Visa Deposit Bank accounts

Diner’s Club

ADD/DELETE

**PLEASE ENSURE YOU HAVE CIRCLED THE CORRECT FUNCTION (ADD/CHANGE/DELETE MERCHANT NUMBER)**

Processing Information
Internet/eCommerce: Data Capture/Settlement:

Currency:

CAN$
Terminal-based: Host-based:

U.S.$

Check only ONE:

Complete a separate Form for each currency

Do you process credit card orders over the internet?

YES

NO

**Check with your Vendor to see which options are supported**

Merchant or Software provider initiates end-of-day GPS automatically closes batch daily at 1:00 a.m
Unattended: POS device is operated solely by the cardholder

POS Attended/Unattended:
Signature:

Attended: POS device is operated by attendant at the site

I agree to verify my bank accounts on a daily and monthly basis, to ensure that I am correctly receiving my deposits from GPS. Date: (MMDDYY)

Fax completed application to: Implementations Department 416-644-5964 GPS Set up Information
This section will be completed by GPS Implementation department and will be forwarded back to you. Please provide this information to your vendor to configure your POS system.
Bank ID/

ICA Plan No. Agent Banks Primary Access No.

Merchant/ Terminal ID Company No. Store No.

/
8 7 7 - 5 5 3 - 5 5 2 7

MCC/SIC Code Backup No.

8 0 0 - 4 6 1 - 4 6 1 4

PLEASE ALLOW UP TO 3 WEEKS FOR IMPLEMENTATION
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Global Payment Systems of Canada, Ltd. Phone (416) 644-5959 (Press Option 1) Fax (416) 644-5964 THIS FORM IS AVAILABLE ON-LINE AT www.globalpaymentsinc.com


				
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