Merchant Information Update

Merchant Information Update Form

Merchant Information
Today's Date:*
Date Format: MM slash DD slash YYYY
Merchant Name (DBA):*
Merchant ID (MID):*
Phone Change:
Primary Phone Number:
Extension:
Cell Phone Number:
Fax Number:
Email Address Change:
New E-mail Address
Would you like Rev19 to send all notifications, updates, newsletters and correspondences to this new email address?
- Yes
- No
Address Change:
Confirm Merchant Name (DBA):
Physical Address:
Street Address Apt/Suite City State Zip Code
Mailing Address:
Street Address Apt/Suite City State Zip Code
Authorization:
Merchant Signature:*
(use your mouse to sign within the box below)
Merchant Printed Name:*
Date*
Date Format: MM slash DD slash YYYY