* Required
One or more of the fields below contain incomplete or incorrect information. Correct the fields highlighted in red to continue.
Your must enter a Date
Date should be numeric
Date is invalid. Please enter Correct Date.
You must enter a Name
Your e-mail address must be formatted like the following example: a@b.c
You must enter Merchant Name
Your must enter a Phone Number
You must enter an Address
You must enter a City
You must enter a State
Your Zip Code must contain 5 numeric digits
You must enter the Number of Locations
Your must enter an Acquirer/Processor Name
Please select one of the Payment Channels
Please select one of the radio button for Surcharge type
*
Date Surcharge will begin
*
Merchant name (Doing Business As)
Please do not enter special characters like &,%,$ etc., in the Merchant Name field.
Merchant contact information
*
Name:
*
Phone Number:
*
Email:
*
Address 1:
Address 2:
*
City:
*
State:
*
Zip Code:
*
Number of locations surcharging
*
Acquirer/Processor Name
*
Payment Channels
Retail face-to-face
Card not present (eCommerce)
Card not present (mail order)
Card not present (telephone order)
*
Type of surcharge (choose one)
Brand
Product
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