Merchant referral form

CUSTOMER INFORMATION

Contact First Name*

Contact Last Name*

Contact Email*

Contact Phone Number*

Registered Trading Name

Corporate / Legal Name*

ABN Number*

Trading Address*

Mailing Address (If Different From Trading Address)

Business Description

Please provide the details of the person who is referring this customer

Referrer Name*

Referrer Email*

By clicking “I agree” you undertake to ANZ Worldline Payment Solutions that you have:

obtained the express consent from each individual to disclose their personal information to us in this form;
sent or shown each individual a copy of our Privacy Policy and the individual is aware how their personal information will be protected and managed by us;
advised each individual that they may opt out from receiving any promotional material by contacting us or clicking the “Unsubscribe” button in any of the emails that we send to them; and
disclosed to the customer you are referring to us in this form that we pay a commission to you for any business you refer to us and that this commission may be paid as a flat fee or based on the customer’s transaction volume for the duration that the customer receives services from ANZ Worldline Payment Solutions.