Merchant Address Change Request

Merchant Name
Merchant ID
Effective Date
Date Format: MM slash DD slash YYYY
Please select the requested change(s) from the options below and then complete the appropriate section(s). For all changes, the authorized signer must e-sign and date. Once completed and signed, click continue, and your document will be submitted.
Check All That Apply
Change Legal Address
Current Legal Address
Street Address Address Line 2 City State ZIP Code
Current Legal Phone
New Legal Address
Street Address Address Line 2 City State ZIP Code
New Legal Phone
Change DBA Address
Current DBA Address
Street Address Address Line 2 City State ZIP Code
Current DBA Phone
New DBA Address
Street Address Address Line 2 City State ZIP Code
New DBA Phone
Owner/Officer Electronic Signature
Owner/Officer Title
Owner/Officer Name
Date
Date Format: MM slash DD slash YYYY

Check All That Apply