Merchant Request Form For office use only (Encircle requested SR/s) MID TID Legal name of the establishment 1 2 3 4 5 6 7 8 1. Updation of Contact Number and E-mail ID Mobile No.* Tel No. 1 E-mail ID Alternate Mobile No. Tel No. 2 (STD Code) (Number) (STD Code) (Number) 2. Updaon of GSTIN GST No.* Please submit GST Registraon Cerficate issued by Govt. of India Direct Credit (Axis Bank account) NEFT (Account with other bank) Exisng account No. (If any) New Account No. New Bank name New Bank branch New IFSC Code For NEFT payment please submit a cancelled cheue 4. Addional MID Addional TID DCC MID Contact person name* Installaon Address* Landmark* City* State* First Middle Last PIN Code Value Proposion Easy Plan Card Transacon Axis eDGE Rewards Redempon E-Chargeslip Merchant App Freecharge Internaonal Transacon Acceptance Merchant Portal Smart Plan Card Transacon Same Day Payment Holiday Payment Axis eDGE Rewards Redempon E-Chargeslip Merchant App Freecharge EMI on POS DCC Merchant Portal Spend Based Cashback Internaonal Transacon Acceptance Bharat QR 4.0 Smart Plus Plan Self-Checkout Soluon Smart Wall Soluon Table Top Soluon Retail Soluon Integrated POS Soluon No. of Tablets 1 3. Change in Payment mode / New account linking
Transcript
Merchant Request Form
For office use only (Encircle requested SR/s)
MID TID
Legal name of the establishment
1 2 3 4 5 6 7 8
1. Updation of Contact Number and E-mail ID
Mobile No.*
Tel No. 1
E-mail ID
Alternate Mobile No.
Tel No. 2
(STD Code) (Number) (STD Code) (Number)
2. Upda�on of GSTIN
GST No.*
Please submit GST Registra�on Cer�ficate issued by Govt. of India
Direct Credit (Axis Bank account) NEFT (Account with other bank)
Exis�ng account No. (If any)
New Account No.
New Bank name
New Bank branch
New IFSC Code For NEFT payment please submit a cancelled cheue
4. Addi�onal MID Addi�onal TID DCC MID
Contact person name*
Installa�on Address*
Landmark*
City *
State*
First Middle Last
PIN Code
Value Proposi�on
Easy Plan
Card Transac�on
Axis eDGE Rewards Redemp�on
E-Chargeslip
Merchant App
Freecharge
Interna�onal Transac�on Acceptance
Merchant Portal
Smart Plan
Card Transac�on
Same Day Payment
Holiday Payment
Axis eDGE Rewards Redemp�on
E-Chargeslip
Merchant App
Freecharge
EMI on POS
DCC
Merchant Portal
Spend Based Cashback
Interna�onal Transac�on Acceptance
Bharat QR 4.0
Smart Plus Plan
Self-Checkout Solu�on
Smart Wall Solu�on
Table Top Solu�on
Retail Solu�on
Integrated POS Solu�on
No. of Tablets
1
3. Change in Payment mode / New account linking
Asset Class
POS
PSTN
GPRS
GPRS + QR
Pocket GPRS
D200 Ez A920 Ez
Smart EDC Ms
N3 Py
Android POS MPOS
Py Standard
Py Insta
Ez
Bharat QR Decal
(Including UPI)
Insta Device Serial
Number for Py
No. of Decals
Asset (No. of terminals)
Easy Plan
Smart Plan
PSTN GPRS GPRS + QR Mobile POS Pocket GPRS Android POS
Back dated / Duplicate statement (Including interna�onal transac�ons statement)
PSTN
7,500
600
GPRS / Pocket GPRS
11,000
600
mPOS
4,000
600
500
5 per roll
Android POS
13,500
600
Bharat QR
50
50
for <= 7 days, 500 per MID
* GST addi�onal at applicable rates **Paper roll will be charged for merchants who are not availing E-Chargeslip, this cost will be charged for any paper roll ordered beyond the rolls supplied on a monthly basis by the Bank
MID
TID
Reason for last deac�va�on __________________________________________________
6. Change of Name Legal Name DBA Name Both
Legal Name of the establishment
DBA / Marke�ng Name*Please submit KYC document as men�oned on our website
7. Change of Address Installa�on Address Registered Address Both
Contact person name*
Address*
Landmark*
City*
State*
Please submit KYC document as men�oned on our website
First Middle Last
PIN Code
8. Deac�va�on
MID
TID
Reason for Deinstalla�on
Refer point no. xvii for termina�on clause
Shop closed No card transac�on Moved to compe��on Service issue
(I) I / We confirm that all the par�culars given herein / above are true and correct. I / We have enclosed the KYC and other important documents as required to process the requests. The person/s signing this form has/ have full legal authority to do so, on behalf of my / our Merchant Establishment. (ii) If at any stage it is brought to the no�ce of the bank that any informa�on submi�ed herein is suppressed / incorrect / false, or that it has been given with a view to willfully mislead the bank, the applica�on / request is liable to be rejected and the Terms and Condi�ons shall also be terminated forthwith, without revoking the bank's rights to proceed legally against the Merchant Establishment and /or the business owners. (iii) I /We agree and accept that Axis Bank shall at its sole discre�on, may reject / accept the Merchant Applica�on format any processing stage. I /We understand that Axis Bank reserves the right to provide me with the EDC type / variant based on certain parameters and eligibility criteria as per their internal policies. (iv) I /We have not been found / pronounced to be of unsound mind by any competent authority and declared / adjudicated as insolvent by any competent court. (v) I /We have not been found guilty of any criminal offence by any court of competent jurisdic�on. (vi) I /We have not been found guilty of or to have knowingly par�cipated in or connived at any fraud, dishonesty or misrepresenta�on against a banker or an insured in the course of any judicial proceeding rela�ng to any bank or in the course of an inves�ga�on of the affairs of a banker. (vii) I /We have not violated the code of conduct specified of any bank or declared a willful defaulter by any bank or /financial ins�tu�on. (viii) I /We hereby understand and agree that it is my/ our responsibility to obtain, read and understand the Terms & Condi�ons related to Axis Bank Payment Solu�ons and hereby undertake to abide by the Terms & Condi�ons as may be in force from �me to �me. Further, I /We understand and agree that use of the facility(s) provided by Axis Bank shall be deemed to be an uncondi�onal and irrevocable acceptance of the said Terms and Condi�ons. (ix) I /We request to accept MDR/ Commission / EMI fees as levied under this Merchant Request Form. I /We agree to pay any charges / fees s�pulated by the bank from �me to �me. (x) I / We acknowledge and accept that the Dynamic Currency Conversion (henceforth termed "DCC") op�on will be selec�vely offered to the cardholder as a choice and not as the default selec�on, highligh�ng the choice of currencies that are offered. I /We also undertake that we will not use language or procedures that will make paying in Indian Rupees difficult, or otherwise cause Cardholders to choose DCC by default. (xi) I / We unequivocally agree and undertake to inform the cardholder of the exchange rate used in DCC transac�on/s and that the choice of currency decided between the merchant and the cardholder is final. I /We agree & undertake to inform the cardholder that the DCC service is being provided by us and our Acquiring Bank ("The bank") and not by VISA/ MasterCard. (xii) From �me to �me, Axis Bank communicated various new products / special features of exis�ng products / promo�onal offers which are of significant benefit to its customers. (xiii) I /We hereby provide my consent to receive informa�on / service etc. for marke�ng purposes through Telephone / Mobile/ SMS / E-mails by the bank and its agents. (xiv) I /We hereby agree to receive the merchant payment report by E-mail only. (xv) I /We hereby agree that the cashback received as part of spend based cashback program is inclusive of all taxes. (xvi) I / We hereby agree that in case I /We fail to maintain minimum monthly average balance in the current account opened as part of this offering, the bank shall be en�tled to charge EDC discounted fee for the par�cular month, which will be in addi�on to the exis�ng Current Account charges as applicable.(xvii) I /We hereby understand that in the event fees and charges payable to bank remain outstanding for more than 90 days from due date, the Bank shall have the right to terminate the services and can mark lien on my/ our account. The lien will be released only a�er the EDC machine is handed over in working / opera�ng condi�ons to the sa�sfac�on of the bank and upon se�lement of all outstanding dues.(xviii) The bank also has right to exercise general lien on any account / deposits held by me / us with the bank and set off the amounts lying therein and / or from monies received as part of future se�lements, against recovery of outstanding dues towards the bank and / or any costs incurred by the Bank on account of damage/ loss of the EDC machine.
Full Name 1 _________________________________________________________________
Date : ______________________________________________________________________
Place : ______________________________________________________________________
Full Name 2 _________________________________________________________________
Date : ______________________________________________________________________
Place : ______________________________________________________________________
For Office use only
Cer�fied that this request form is complete in all respect & all relevant documents are obtained and verified. The request may please be processed.The MRF has been personally submi�ed by the merchant / the merchant representa�ve. I have verified iden�ty of the merchant by verifying the ID proof / KYC document with merchant details in system.
Date of request received
Request Accepted by _____________________________________ Employee No. ____________________________________________ Signature _____________________________________
Acknowledgment to Merchant
MID
Date of request received
Name of Merchant Acquiring Officer ________________________________________________________________ Signature ________________________________________________________
Please not : Your request will be processed within 7 working days.
Merchant name ________________________________________________
