Name:__________________________________________________________
Address: ________________________________________________________
City: ___________________________________________________________
State/Province: ______________________Zip/Postal Code: _______________
Phone: (____)_________________Fax: (____)__________________________
Contact Name: ___________________________________________________
Contact Phone: (____)______________________________________________
Contact Email: ____________________________________________________
Country Code [3]: __________________________________________________
City Code or Zip Code [5]: ___________________________________________
Merchant ID [12]: ___________________________________________________
Bank Bin # [4]: _____________________________________________________
Terminal ID [16]: ____________________________________________________
Note: When entering the data into PC Authorize Hub for the "first 12 digits of Term ID" use the Bank Bin number and the first 8 digits of Terminal ID. For "Remaining digits Term ID" use the remaining 8 digits of the Terminal ID.
Primary Authorization Phone: (_____)___________________________________
Alternate Authorization Phone: (_____ )__________________________________
Primary Settlement Phone: (_____)______________________________________
Alternate Settlement Phone: (_____)____________________________________