Global Payments Change Request

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This field is for validation purposes and should be left unchanged.

Trading Name

Terminal ID

Global Payments Contact (email only)

Contact Name

Contact Phone

Address

Refund

On

Off

SmartConnect (Integration)

On

Off

Surcharge Credit %

Surcharge Debit $

AMEX Surcharge %

AMEX MID (if known)

Quantity of Terminals

Requirements

Paper Rolls (Quantity)

Please select a number of paper rolls if required, in increments of 30.

Return Satchels (Quantity)

Please enter the number of return satchels required.

Additional Information

Contact Name

Address

Please cancel my terminal effective from

Reason for Cancellation

List any additional TIDs