Anz Merchant Services Additional Terminal Request (pdf 356kb)

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ANZ Merchant Services Additional Terminal Request Commercial Customers only. Please use this form if you wish to order an additional terminal for an existing site. *Denotes mandatory field. MERCHANT DETAILS Merchant Number* Existing Terminal ID*             (This number can be found on your merchant statement) Company Name                     Trading Name* Trading Address Street Address* (Where terminal will be located) Suburb/Town* State* Postcode* Postal Address (If different from above) Suburb/Town State Postcode Attention of: Contact Name Title First Name* Last Name* Contact Phone Number* ( ) Mobile Phone Number* Email* You acknowledge that ANZ may use this email address to keep you informed of the progress of this request. TERMINAL AND DELIVERY INFORMATION Number of Additional Terminals*: Please note the additional terminal/s will replicate the existing terminal type of the Merchant Number provided. Cable Requirements* USB Serial Ethernet (CAT 6) Line Type** **Required for POS Turbo 2, POS Turbo Plus and POS Plus 2 Other. Please Specify: Preferred Delivery Date (dd/mm/yyyy) Delivery Contact Name*     (Must be at least 5 business days from today) Contact Phone Number* ( ) Mobile Phone Number* Please note: The additional terminal(s) will be delivered/installed to your current trading address. Special Instructions (Maximum 300 characters) Australia and New Zealand Banking Group Limited (ANZ) ABN 11 005 357 522. Page 1 of 2 ANZ Merchant Services Additional Terminal Request MERCHANT’S AUTHORITY Important Information Australia and New Zealand Banking Group Limited ABN 11 005 357 522 (ANZ) is collecting the personal information of the contact listed above in order to action the request set out in this form. By ticking this box, I/we declare that the individual/individuals concerned is/are aware or I/we will immediately make them aware of the following: 1. ANZ’s contact details; 2. ANZ is collecting their personal information from me/us in order to action the request set out in this form. Without this information, ANZ may be unable to action this request; 3. ANZ may disclose their personal information to: any agent, contractor or service provider ANZ engages to carry out or assist its functions or activities; any related entity of ANZ; participants in the card scheme; and other financial institutions; 4. ANZ may disclose their personal information to recipients located overseas. Information about where overseas recipients may be located can be found in ANZ’s Privacy Policy and at www.anz.com/privacy; 5. ANZ may use their personal information or disclose their personal information to its related entities or organisations that are in a product or marketing alliance with ANZ (alliance partners) to help ANZ, its related entities or alliance partners to promote or provide a product or service. If they do not want ANZ to tell them about its products and services or those of its related entities or alliance partners, they may call 13 13 14 at any time to withdraw their consent; 6. ANZ’s Privacy Policy (found at www.anz.com/privacy) also contains information about how the individual/individuals concerned may access or seek correction to their information, and raise concerns that ANZ has breached the Privacy Act or an applicable code and how ANZ will deal with those matters; and 7. A one off establishment/connection fee of $99 (inc. GST) is payable to ANZ per additional terminal requested. Additional terminal rental fees and charges will apply (where applicable) as per your current terminal rental agreement. By ticking this box, I/we hereby authorise ANZ to action the request set out above. Director / Partner / Sole Proprietor / Authorised Representative Director / Partner / Sole Proprietor / Authorised Representative 1. Print Name* 2. Print Name Date* (dd/mm/yyyy)     Date (dd/mm/yyyy)     HOW TO SUBMIT Please note: All check boxes must be checked and mandatory fields completed before ANZ can process this request. Submit via email Mail to: ANZ Merchant Services Locked Bag 10 Collins Street West Post Office Melbourne, VIC, 8007 Fax to: 1300 789 933 Australia and New Zealand Banking Group Limited (ANZ) ABN 11 005 357 522. Australian Credit Licence Number 234527. Item No. 86676 10.2015 W477672 Page 2 of 2