Merchant Information Update Form Merchant InformationToday'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 AddressWould you like Rev19 to send all notifications, updates, newsletters and correspondences to this new email address?YesNoAddress 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