Application for Merchant Facilities

Merchant New Accounts

Level 12, 150 George Street
Parramatta NSW 2150
Phone: 1800 230 177
To
From
Branch number Branch/Department name Name of ofcer completing this application
Facsimile number Telephone number
Section 1 Application details
MasterCard Visa Debit
1. Nominated cards
AMEX/JCB number Diners number
2. Product
EFTPOS Mobile Leo iPod Leo iPhone Unattended EFTPOS Lite EFTPOS Plus
Card present products
XPOS DCC MediClear IP @ POS Contactless
Product options (Options not available on all products)
BPOINT CommWeb
Card not present
Please specify hardware model if required
Internet Merchant Account.
HealthPoint EFTPOS Integrated (specify model) MICROS (specify model)
Barcode Reader Micros Axis GPRS
4. Merchant facilities
New merchant facility processing method
Existing Commonwealth Bank merchant number
5 3 5 3 1 0 9
3. Terminal features
Pre-Authorisation 7 day totals Trans print Multi-Merchant PinPad lock Tipping Shift totals
Trading name
5. Business details
Registered business number ABN/ACN
Registered business name
Name(s) of registered owners
Title Surname Full given name(s)
Drivers Licence number OR Passport number Date of birth Email address
Drivers Licence number OR Passport number Date of birth
Title Surname Full given name(s)
Email address
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Section 1 Application details (continued)
Email address
Facsimile number Telephone number Mobile number
if not trading from a fixed address
How long has the business been established?
years months
6. Contact details
Position
Title Surname Full given name(s)
7. Goods and/or services
Describe the type of goods or services that your business provides
What is the maximum time between payment for and delivery of goods and services? Days
Yes No Do you store, or intend on storing, cardholder information?
List your PCIDSS Compliant provider
Yes No Are you compliant with the PCI DSS?
Yes No Are all your technology and payment service providers compliant with the PCI DSS?
Address of business premises (PO Box is not acceptable)
State Postcode
Postal address (if different to above)
State Postcode
8. Are you a member or customer of any association, franchise or buying group?
Yes
Name of association, franchise or buying group Link ID
No
9. Trading Information
Estimated % of international credit cardholder transactions out of the above weekly total
%
$
Debit
$
Credit
$
Debit
$
Credit
Average ticket size
How long have you held this account?
10. Banking details
Complete if separate account number is required for fees/charges
BSB Account number Full account name
BSB Account number Full account name
11. Equipment
Manual imprinter Number required Electronic terminal Number required
or Principal terminal user Secondary terminal user For Multi-Merchant please specify
12. Special Facilities
MOTO Internet order Other
Do you take payment for goods and services prior to their delivery?

Yes if yes what % of the estimated turnover does this relate to?
%

No
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1
Section 1 Application details (continued)
14. Receipt message
Maximum of 20 characters e.g. Thank you
13. Internet details
For businesses that operate through websites, please provide URL/domain name (must be a working website.)
Business email address
Support branch BSB number
Settlement time 9:45pm AEST Other preferred time between midnight and 9:45pm AEST
15. Settlement
Bulk credits (if more than 1 terminal) Yes No Is everyday settlement required? Yes No
Bulk fees/charges Yes No
16. Fees
17. Special installation requirements
Refer to Fee Schedule
18. Declaration, authorisation and acknowledgement
Section 2 What you agree to
Date website created
D D / M M / Y Y Y Y
Acknowledgment and authorisation
We collect the information in this application and other information about you to assess your application and administer your facility.
You includes any directors of the entity applying for the facility. We and other members of the Commonwealth Bank Group also
use this information from time to time to tell you about products and services offered by the Group, afliated providers and external
providers for whom we act as an agent.
You must provide us with accurate and relevant information. If you do not, we may not be able to provide you with the facility you are
seeking. You authorise us to undertake checks, including obtaining commercial credit reports about you from credit reporting agencies.
Where not all directors are signing this application, those who are signing conrm that those who are not, are aware of this.
We may disclose your information to persons who refer you to us, other members of the Commonwealth Bank Group, and our
service providers, or as permitted or required by law. For further information including how to access your information, please see
our Privacy Policy Statement available at www.commbank.com.au.
If you have provided your email or mobile phone details, we may communicate with you electronically
regarding your merchant facility as well as to provide you information about the Groups products and services.
If you do not wish to receive marketing information please call 1800 230 177.
Direct Debit Request (DDR) applies where the banking account you nominate in this application (or if more than one, the one
for payment of fees and charges) is not with us.
You authorise and request Commonwealth Bank User ID 1191 (fees, chargebacks and other amounts relating to credit cards)
and User ID 00952 (fees, chargebacks and other amounts relating to EFTPOS transactions) to arrange for funds to be debited
from your nominated account through the Bulk Electronic Clearing System (BECS). You authorise the Bank to verify the details
of the account with your nancial institution and warrant that you have account authority to sign this DDR. If you do not have
account authority, please contact us and we will provide a separate form for the signatories to complete.
You acknowledge that this authority is governed by the Direct Debit Service Agreement set out below.
If eligible you may be able to accept UnionPay cards.
Declaration
You declare that you are not an undischarged bankrupt.
You declare that you have never had a merchant facility refused or terminated by any bank or under any card scheme.
You acknowledge that the terms and conditions for this facility (the Merchant Agreement) will be provided at time of installation.
The Merchant Agreement is also available at http://www.commbank.com.au/business/pds/customer_merchant_agreement.pdf.
You should read and understand the Merchant Agreement before processing the rst transaction under this facility, as it applies
from that point.
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THANK YOU

Signature Date
Position Name

Signature Date
Position Name
Latest company balance sheet and profit & loss statement or completed personal balance sheet for sole proprietor or partnerships
Merchant Endorsement Form (internal use only)
A copy of either a cheque account statement, deposit slip or blank cheque
Authority for Non-Personal Accounts (A153)
Explanation/Reason for termination of merchant product from another acquirer
What we require you to send back:
Section 2 What you agree to (continued)
Section 3 Direct Debit Request Service Agreement applies where your account is not with us.
Please retain this section for your records.
1 Debiting your account: By signing a DDR, you authorise us to arrange for funds to be debited from your nominated
account according to the agreement we have with you and the merchant agreement referred to in the declaration section
above. Wewill keep your direct debit records and account details private unless this information is required by us to
investigate a claim relating to an alleged incorrect or wrongful debit, or as otherwise required by law. In the event of a debit
returned unpaid, we may attempt to contact you to discuss payment arrangements and/or we may attempt a redraw on
your account.
2 Enquiries: If you believe there has been an error in debiting your account, you should call us on 1800 230 177 (freecall) and
conrm the details in writing with us as soon as possible so that we can resolve your query quickly. If our investigations
show that your account has been incorrectly debited, we will arrange for your nancial institution to adjust your account
accordingly. We will also notify you in writing of the amount by which your account has been adjusted. If our investigations
show that your account has not been incorrectly debited, we will respond to your query by providing you with reasons and
copies of any evidence for this nding. Any queries you may have about an error made in debiting your account should be
directed to us in the rst instance so that we can attempt to resolve the matter between you and us. If we cannot resolve the
matter, you can still refer it to your nancial institution.
3 Changes by us or you: We may vary any details in this agreement or a your DDR at any time by giving you at least 14
days written notice. You may cancel, defer and alter your authority for us to debit your account at any time by giving us
10 business days notice in writing before the next debit payment to be made. This notice should be given to us in the rst
instance. You may also stop or cancel direct debits by contacting your nancial institution.
4 Your responsibility: You should:
check with the nancial institution where your account is held before signing this application form as direct debiting
through the Bulk Electronic Clearing System (BECS) is not allowed on the full range of accounts. You should also complete
your account details (including Bank State Branch (BSB) number) directly off a recent account statement from your
nancial institution. If you are in any doubt, please check with your nancial institution before completing the
drawing authority.
ensure there are sufcient cleared funds available in your account to allow a debit payment to be made;
ensure that suitable arrangements are made if the direct debit is cancelled:
by yourself; your nancial institution or for any other reason.
5. Denitions
Account means the account you nominate on page 2 (or if more than one, the one for payment of fees and charges).
Banking day means a week day other than a day thats a public holiday.
Us and We and Our means Commonwealth Bank of Australia ABN 48 123 123 124.
You means the customer(s) who signs this application form.
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