MERCHANT FORM - WEB SECURITY ACCESS

pyknicassortedΑσφάλεια

3 Νοε 2013 (πριν από 3 χρόνια και 10 μήνες)

67 εμφανίσεις

MERCHANT FORM
-

WEB SECURITY ACCESS






Web Access Security Form
-
Merchant


WEBACESS
MERCH
-
SETTLM
-
002

(
03/09
)


PLEASE

COMPLETE, SIGN AND

RETURN THIS

FORM
TO CARDTRONICS

VIA FACSIMILE TO
(832) 308
-
4809


Company
Information
:


(please print c
learly in blue or black ink only)


Requestor Name:








Company Name:








Select One
:
(
che
ck one box
)


New Access


Existing Cardtronics
Web
User


Existing Cardtronics
Web
User ID:









Signature:








Printed Name:







Date








Street Add
ress:









City:








State





Zip Code








Tax ID No:
(
mandatory
for v erification purposes)







(For more than one Tax ID please use attached sheet)


Termi nal

Informat
i on:


Terminal ID No:









More TIDs on Attached Sheet


(For more than one Terminal ID please use attached sheet)


Physical Street Address of ATM:









City:








State





Zip Code








Web Access / Grant Web Access to
:


1.


Last Name:








First Name:








Telephone No:








Email Address:









Transactions Onl
y



Settlement Data


2
.


Last Name:








First Name:








Telephone No:








Email Address:









Transactions Only



Settlement Data




Dealer Printed Name
:








Signature
:








FOR MULTIPLE TERMINA
L IDS AND OR MULTIPL
E TAX IDS, PLEASE US
E THE FOLLOWING SHEE
T.



MERCHANT FORM
-

WEB SECURITY ACCESS






Web Access Security Form
-
Merchant


WEBACESS
MERCH
-
SETTLM
-
002

(
03/09
)

Company
Information
:



Company Name:









Additional Terminals:


2.

Terminal ID No:








3.

Terminal ID No:








4.

Terminal ID No:








5.

Terminal ID No:








6.

Terminal ID No:








7.

Terminal ID No:








8.

Terminal ID No:








9.

Terminal ID No:








10.

Terminal ID No:








11.

Terminal ID No:








12.

Terminal ID No:








13.

Terminal ID No:








14.

Terminal ID No:








15.

Terminal ID No:








16.

Terminal ID No:








17.

Terminal ID No:








18.

Terminal ID No:








19.

Terminal ID No:








20
.

Terminal ID No:








21
.

Terminal ID No:








22
.

Terminal ID No:








23
.

Terminal ID No:








24
.

Terminal ID No:








25
.

Terminal ID No:








26
.

Terminal ID No:








27
.

Terminal ID No:








28
.

Terminal ID No:








29
.

Terminal ID No:








30
.

Terminal ID No:








31
.

Terminal ID No:








32
.

Terminal ID No:








33
.

Terminal ID No:








34
.

Terminal ID No:








35
.

Terminal ID No:








36
.

Terminal ID No:








37
.

Terminal ID No:








38.

Terminal ID No:








39.

Terminal ID No:








40.

Terminal ID No:








41.

Terminal ID No:








42.

Terminal ID No:








43.

Terminal ID No:








44.

Terminal ID No:








45.

Terminal ID No:








Addi ti onal Tax ID No:


3.

Tax ID No:








4.

Tax ID No: