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Merchant Detail Form
If you like to sign up for any of our EFTPOS terminals/packages, please fill out the form and click on the "Submit" button below. Please read our Privacy Statement before submitting your application. Filling out all fields will help us provide you with the best EFTPOS solution for your business.
Full legal name of business:
Postcode of trading address:
Postcode of mailing address:
Website address of your business:
Full description of business:
Do you have an existing merchant facility? (Tick the applicable below).
If yes please provide a copy of your merchant statements with this form.
Copy of merchant statement
upload new file
Please upload a scan of your latest merchant statement here.
Please provide AMEX Diners and JCB numbers below if you have them:
BSB and account number to credit funds to:
BSB and account number to debit fees from:
Average transaction size $:
Total annual business turnover $:
Please provide an estimate for all three figures.
Do not enter anything in this field:
indicates a required field
Level 32, 1 Market St, Sydney 2000 NSW
PO Box 545, Darlinghurst NSW 1300 Australia
1800 MR ATMS (1800 672 867)
Tel: +61 2 9275 8841
Fax: +61 2 9275 8800
A.C.N.: 111 571 076, A.B.N.: 72 111 571 076.
All text COPYRIGHT © MANDRAKE.ATM 2004-2013 unless specified otherwise.
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