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Home / Merchants / Become a Merchant

Become a Merchant

Merchant Enquiry Form.

You can use this form as the first step towards becoming a merchant, or to add a new site to your group.

Do you want to *

Become a Merchant

Add a new Site/Location

Please complete all details below, * denotes a mandatory field. A member of the Merchant Support team will contact you to finalise your request.

Please complete all details, * denotes mandatory fields.

Date

19/05/2012

Type*

New Build

Take Over

New Build/Take Over Date*

Contact Name*

Email*

Company Name*

Site Name*

Site Street Address*

Site Suburb*

Site State*

Site Postcode*

Postal Address

Postal Suburb

Postal State

Postal Postcode

Phone Number*

Fax Number

Service Type*

Fuel

Non-Fuel

Merchant Type*

Motorpass

Motorcharge

Wright Express Terminal Required*

Yes

No

If yes is Eftpos required?*

Yes

No

Captcha

Enter in text shown in image *

If you cannot view this image, please contact Merchant Support on 1300 130 113.

Merchant Name *

Existing Merchant Number *

Contact Name *

Email *

Company Name *

Site Name *

Site Street Address *

Site Suburb *

Site State *

Site Postcode *

Postal Address

Postal Suburb

Postal State

Postal Postcode

Phone Number

Fax Number

Service Type *

Fuel
Non-Fuel

Merchant Type *

Motorpass
Motorcharge

Wright Express Terminal Required *

Yes
No

If Yes is Eftpos required

Yes
No

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