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ADDRESS/PHONE/FAX CHANGE…
Tags: address phone, address street, business fax, business phone number, change request form, city state zip, cooperation, customer service number, mailing address, merchant application, merchant name, merchant number, phone fax, physical address, signature, state zip code,Pages: 1
Language: english
Created: Thu May 20 14:49:54 2004
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ADDRESS/PHONE/FAX
CHANGE REQUEST FORM
IMPORTANT - PLEASE READ BEFORE PROCEEDING:
ALL INFORMATION LISTED IS REQUIRED AND MUST BE COMPLETED.
PLEASE FAX THIS REQUEST FORM TO CUSTOMER SERVICE AT 425-969-2945.
THIS REQUEST WILL NOT BE EFFECTIVE UNTIL THE SIGNATURE
HAS BEEN VERIFIED BY CUSTOMER SERVICE.
Thank you for your cooperation.
Merchant Name: ________________________________________________________
Merchant Number: _____________________________________________
Old Address:
_____________________________________________ _____________
Street Unit/Suite/Apt.
____________________________________ _________ ___________
City State Zip Code
New Physical Address: (If P.O. Box, below must also be completed)
_____________________________________________ ____________
Street Unit/Suite/Apt.
____________________________________ _________ ___________
City State Zip Code
New Mailing Address: (If P.O. Box, above physical address must also be completed.)
_____________________________________________ ____________
Street Unit/Suite/Apt.
____________________________________ _________ ___________
City State Zip Code
New Merchant Phone Number(s):
Business: ( _____ ) ______ - _______
Fax: ( _____ ) _____ - ________
Customer Service number, if different than business phone number.: ( _____ ) _____ - ______
________________________________________________________ __________
Signature of Authorized Principal Date
(as specified on the Merchant Application/Agreement)
If you should have any questions, please contact our Customer Service department at
(800)675-6573 or email us at support@appliedmerchant.com