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Reopen Merchant Account Request FORM Fax Instructions Mailing Instructions Please complete the form below and fax it to Fax 888-415-0052 Attn Merchant Services or email to support merchantserviceshq. comMSRCTF merchant services 21650 Oxnard Street Ste 1200 Woodland Hills CA 91367 Business Information Business LEGAL Name Business DBA Name if different than legal name Business Legal Address Business Physical Address if different than legal address City State Zip Main Contact First Name M. I. Phone Number local / landline Last Name Toll Free Number if applicable Mobile / Cell Phone if applicable Email Address FAX Number Federal Tax ID Required for Partnerships and Corporations 9 digits Ownership Information Owner / Partner / Officer First Name Title in Business Ownership Percentage Social Security Date of Birth Home Address important information For Member Bank For Global Direct Wells Fargo Bank National Association Merchant Support Group Walnut Creek CA Global Payments Direct Inc* 10 Glenlake Parkway North Tower Atlanta Georgia 30328 Cardholder data storage compliance Have you ever experienced an account data compromise If yes when I am using point of sale terminal hardware and software or a PCI DSS Certified Internet Gateway Provider supplied by my No I am not using one of the above products. Please complete the following questions. What third party software company/vendor did you purchase your POS Application from What is the name of the third party software Version Do your transactions process through any other third parties web hosting companies or gateways Yes No If yes with whom Do you or your vendor receive pass transmit or store the full cardholder number electronically If yes where is card data stored Merchant Third Party Only Both Merchant Third Party 1. Are you or your vendor PCI/DSS Payment Card Industry /Data Security Standard compliant GAA Export Only 3. Date of compliance Date of last scan Card Association requirements dictate it is prohibited to store track data in any circumstance. Further it is recommended that no merchant or a merchant s third party vendor store acceptance. REQuired SIGnatures Print Name Sign Here MID Owner s Signature Date. comMSRCTF merchant services 21650 Oxnard Street Ste 1200 Woodland Hills CA 91367 Business Information Business LEGAL Name Business DBA Name if different than legal name Business Legal Address Business Physical Address if different than legal address City State Zip Main Contact First Name M. I. Phone Number local / landline Last Name Toll Free Number if applicable Mobile / Cell Phone if applicable Email Address FAX Number Federal Tax ID Required for Partnerships and Corporations 9 digits Ownership Information Owner / Partner / Officer First Name Title in Business Ownership Percentage Social Security Date of Birth Home Address important information For Member Bank For Global Direct Wells Fargo Bank National Association Merchant Support Group Walnut Creek CA Global Payments Direct Inc* 10 Glenlake Parkway North Tower Atlanta Georgia 30328 Cardholder data storage compliance Have you ever experienced an account data compromise If yes when I am using point of sale terminal hardware and software or a PCI DSS Certified Internet Gateway Provider supplied by my No I am not using one of the above products.

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