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E.g. "Myer, Target"         E.g. "Paddington, Brighton"

Sales Reference Number (if known)

To ensure minimal delays and efficient processing of your agreement:

  • * Ensure terminal details are provided

  • * Supply a voided cheque, deposit slip or bank statement copy

Is this a change of ABN/ACN?

Is this a change of ownership?

Previous owner's final trading date

Previous owner's Merchant Number

Trading Name (Maximum 40 Characters)

Trading Address (Physical site address required)

Suburb

State

Post Code

Business Phone

Business Fax

Email Address

Postal Address (If different from Trading Address)

Suburb

State

Post Code

Business Phone

Business Fax

Where would you like your Welcome Pack to be sent?

GST Supply Type:

Description of business (i.e. Hardware, Japanese Restaurant, etc)

Affiliated Brand/Organisation

If the Merchant Application is for a Trust, a copy of the Trust Deed is required. Please supply a copy of the Trust Schedule* (usually 1 page) and/or Trustees Signatory Page, confirming that the Trustee is the same individual(s) listed on the application. * Please note we do not require the complete Trust Deed.

Name of Company, Corporate Entity, Partnership, Trust

Australian Company Number (ACN)

Australian Business Number (ABN)

Number of years in business

Estimated Diners Club turnover (Annual)

Proprietor 1 / Owner / Director

Home Address

Suburb

State

Post Code

Date Of Birth

Home Phone

Drivers Licence Number

State of Issue

Proprietor 2 / Owner / Director

Home Address

Suburb

State

Post Code

Date Of Birth

Home Phone

Drivers Licence Number

State of Issue

Do you currently have / held / or have ever been:

A Diners Club Card?

Membership Number (if known)

A Diners Club Merchant?

Name Of Merchant

Previous Merchant Number

BSB Number

Account Number

Bank

Name of Bank Account (Please note: Name of Bank Account must match Name of Company, Corporate Entity, Partnership or Trust)

Payment Description to appear on Bank Statement (Store Number / Code; Leave blank for Diners Club Merchant Number to appear)

Direct Credit Summary (Statement) issued:

Direct Credit Summary (Statement) delivery method:

Please provide a voided cheque, deposit slip or bank statement copy with your application via the following methods:

Email: merchant.ops@dinersclub.com.au

Fax: (02) 8003 2940

Post: Diners Club Merchant Sales, GPO Box 40, Sydney NSW 2001

Bank Terminals supplied by

Merchant ID

Site ID / CAIC ID / Retailer ID

Terminal ID

Merchant ID

Site ID / CAIC ID / Retailer ID

Terminal ID

Merchant ID

Site ID / CAIC ID / Retailer ID

Terminal ID

Do you accept mail orders, telephone and / or Internet sales?

What are the products sold?

Where does the Merchant operate?

Where are the products stored?

Can you view them?

What is the percentage of payments conducted via mail order, phone or Internet?

%

How are the products delivered? (ie. Mail, Courier, Hand Delivered)

Merchant website address:

Do you currently accept card payments through your website?

Is the website encrypted?

Name of Encryption Software:

NOTE: If you do not currently accept payments on the internet but intend to do so in the future, please inform Diners Club.

Diners Club need to approve the encryption software and ensure that it is a secure website.

Declaration and Privacy Consents and Notifications

Declaration

By completing this Application, the business (A) warrants that all the information in this application is true and correct and not misleading; (B) acknowledges that it will be bound by the Diners Club Merchant Terms and Conditions (which will be provided on approval of this application or viewed at www.dinersclub.com.au); (C) confirms that the GST related information supplied above is true and correct. Diners Club must be contacted should there be any change to any information on this form including the GST status of the company, such as its supplies either ceasing or starting to be solely GST payable, or its registration or de-registration for ABN or GST purposes. By submitting this application, you warrant to Diners Club that you have the authority to complete this application on behalf of the business. If your business is a: Company: Required signatory is the Company Director. Please provide ACN, refer to Ownership Details section. Trust: Required signatory is the direct Trustee or person named on the Trust deed, nominating either a) Company name and ACN b) Individual, names of person/s listed on Trust deed. Refer to Ownership Details section. Partnership: Required signatory is a Partner of the business. Please provide partnership name. If the business is a partnership, you undertake to advise Diners Club if the partnership is dissolved or restructured. Refer to Ownership Details section. Sole Trader: Required signatory is the Sole Trader. Please refer to Ownership Details section. Government Department: Required signatory is person/s authorized by government policy as a signatory. Regular payments. If you process regular payments, you must provide customers with an easy means of informing you of changes to their card account details or their wish to cancel their regular payment arrangements. You must action all customer requests within 5 business days of your receipt. All regular payment transactions must be authorised.

Privacy Consents and Notifications

This section sets out important privacy consents that you give us by completing this application. It also sets out important information about our collection, use, disclosure and management of your personal information. In this section, 'we/us' means Diners Club Pty Limited ("Diners Club") and 'you/your' means all customers named in this application and other individuals (such as guarantors, directors or shareholders) connected with those customers.

1) We collect, use and disclose your personal information: to assess this application and future applications; to provide and manage your products, accounts and services and to manage your relationship and arrangements with us; so we can comply with applicable laws both in Australia and overseas (for more details about relevant Australian laws please see our Privacy Policy); and for other purposes as listed in our Privacy Policy.

If you do not provide us with the information we ask for or the information provided is incorrect or incomplete, we may not be able to assess your application or provide or manage the products or services that you are (or if you are not the applicant, that the applicant is) seeking.

2) We usually collect your personal information directly from you but sometimes we may need to collect personal information about you from third parties. This may include, for example, where we need information from a third party to assist us to process your application or to assist us to locate or communicate with you.

3) We may disclose to, and obtain from, the following organisations personal information about you for the purposes described above (as well as otherwise permitted by the Privacy Act):

· our related companies in Australia and overseas;

· any signatory to the product for which you are applying;

· any broker, financial, legal or other adviser acting in connection with your product or application;

· regulatory and tax authorities in Australia and overseas;

· any insurer relating to your product;

· organisations wishing to acquire an interest in any part of our business for assessing or implementing any such acquisition;

· organisations that carry out functions for us or on our behalf including mailing houses, data processors, researchers and collection agents; and

· other organisations as further set out in our Privacy Policy.

4) Some of the recipients to whom we disclose your personal information may be based overseas. (For example, a disclosure to an overseas recipient may be necessary for operational reasons - such as because you have requested an international payment to be made or another product or service that involves an international element - or to comply with foreign legal or regulatory requirements. We may also use service providers based overseas).

It is not practicable to list every country in which such recipients are located but it is likely that such countries will include the United States of America, India, the Philippines and Singapore. You acknowledge that by consenting to us disclosing your personal information to overseas recipients, Australian Privacy Principle 8.1 will not apply to the disclosure and as a result we may not be liable under the Privacy Act if the recipient does not act consistently with the Australian Privacy Principles. By completing this application form you consent to disclosures to overseas recipients.

5) You can view the Diners Club Privacy Policy on our website www.dinersclub.com.au/privacy or obtain a copy by calling us on 1300 360 060. This policy includes information as to how you can access and/or seek correction of the personal information we hold about you. A charge may apply for providing you with access to your personal information. Our Privacy Policy also contains information as to how you can complain about a breach by us of the Privacy Act and how we will deal with such a complaint.

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