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*** MERCHANT INFORMATION WORKSHEET ***
CONTACT INFORMATION
NAME OF ACCOUNT: ___________________________________________________
(FOR INTERNET ACCOUNTS PLEASE LIST THE NAME AS IT APPEARS WITH YOUR INTERNET PROVIDER)
MERCHANT DBA NAME/S: ___________________________________________________ PHYSICAL ADDRESS: ___________________________________________________
CITY: ________________________ STATE: ______ ZIP CODE: ______________________ CURRENT DISCOVER CARD MERCHANT NUMBER: 6011-______-_____-_____-_____ PRIMARY CONTACT: ________________________________________________________ PHONE: (___)___-_____ EXT:_____ FAX: (___) ___-_____
EMAIL ADDRESS: _______________________ WEB ADDRESS: ____________________
OUR AGENCY WILL ACCEPT CREDIT CARDS FOR PAYMENT OF _______________ Federal Tax ID Number: __-_______ Annual Gross Revenue Collected by Your Agency: _________ Average Ticket Amount _____ Estimated Annual Sales _______ Est. Credit Sales _______ Processor Name, Telephone and Merchant ID #: _______ (___)____-_____ ______
SETTLEMENT INFORMATION (ACH)
Account Name at bank _________________________________________________________ Settlement Information: Bank Name: ____________________________ Phone: (___)____-_____
ABA Transit Routing Number: _ _ _____________ Account Number __________________
9 Digit number located on bottom left corner of deposit slip
Debit fees and/or adjustments from the following account if different from depository account above: Bank Name: ___________________________ Phone: (____)____-_____
ABA Transit Routing Number: _________________ Account Number _________________
9 Digit number located on bottom left corner of checking slip
DBS Boarding Form
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REPORTING
Please send mailed reports as follows: Send Merchant Daily Letter to: (Address) __________________________________________ (City) ____________________ (ST) ___ (Zip) ____________ (Attn.) _____________________
Send Monthly Statements to: (Address) ___________________________________________ (City) ____________________ (ST) ___ (Zip) ____________ (Attn.) _____________________
Chargebacks & Ticket Retrieval Requests to:
(Address) _____________________________
(City) ____________________ (ST)___ (Zip) ____________ (Attn.) ____________________ Our agency prefers to receive reports electronically via email ___ or by fax ___ (check one) Fax Number to deliver reports: Email Address to Deliver Reports: (____)____-_____ ______________________________________________
Prepared by: Signature:
Date: Title:
Please return this form by fax or email to Mark Shapiro at Discover Network Fax: (732)-332-0113 Email: markshapiro@discover.com
If you have any questions on completing this form, please contact Mark at (800)-229 -0058 Ext. 585
(TO BE COMPLETED BY DISCOVER CARD: MCC CODE:
DISCOUNT RATE:
)
DBS Boarding Form
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