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Business Details
ABN
ACN
Registered Business Name
Registered Trading Name
Incorporation Status
Incorporation Status
Individuals (not registered)
Business name (registered)
Company
Incorporated Body
Other
Trading Address
Street Address
State
NSW
VIC
TAS
ACT
QLD
WA
SA
NT
State
Suburb
Postcode
Phone no.
Mailing Address
Same as trading address
Street Address
State
NSW
VIC
TAS
ACT
QLD
WA
SA
NT
State
Suburb
Postcode
Contact Details
Title
Mr
Mrs
Ms
Miss
Dr
Title
First Name
Last Name
Position
Director
Manager
Office Manager
Owner
Secretary
Financial Controller
Position
Contact Email
Contact Phone
Website
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Business Information
Business Description
Projected number of transactions per month?
Projected average transaction value?
Percentage of sales future dated
Average number of days to delivery of goods/services?
Does your business current have a Merchant Facility?
Yes
No
Does your business current have a Merchant Facility?
Have you ever had a Merchant Facility terminated?
Yes
No
Have you ever had a Merchant Facility terminated?
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Director's Details
First Name
Last Name
Date of Birth
Banking Details
This will be where funds are settled to and where fees are debited from.
Bank Name
Account Name
BSB
Account number
Supporting Document
Please provide a PDF copy of your
Bank Statement for the settlement account above
to ensure there are no delays
Select a PDF file
Acknowledgement
By submitting this application, you acknowledge the Terms and Conditions and confirm all information provided is accurate.
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