Secpay registration form

Please complete and print  the registration form below in block capitals and send it to the address alongside with a cheque for £50.00 + VAT (£58.75) made payable to SECPay Limited. Alternatively supply your credit card details. Please note that this account set-up fee is not refundable.  SECPay Limited
51 St. Marys Road
Tonbridge, Kent
TN9 2LE
Tel : 01732 300 200
Customer Registration

For your convenience you may complete most of the fields before you print this form .
CONTACT DETAILS
Contact Name : Primary contact in the company
Company Name :  
Trading address :
Normal address for written correspondence
Town/City :  
County/State :  
Country :  
Postcode :  
Telephone No : Normal Contact Phone Number
Fax No :  
E-Mail : This is the email address for notification of authorised orders.
Url : Leave blank  if unknown at this stage.
Title for 
your order
confirmation Email :		 If you are trading under a different name from the company name, we will place this in your email notification to your customers.
Your office admin Email : Email address for us to send you information about your account, changes in the system etc.
BUSINESS DETAILS
Name of your Bank : This is the name of the bank to which your money is cleared.
Web Design Company : Enter the name of your Web Design Company
if none write none.
Web Design Contact Name : The name of your Web Design Company contact person
Web Design Contact tel. : The Web Designers contact telephone number
First hear about SECPay :

MySimpleshop
MERCHANT ACCOUNT DETAILS

NOTE : 
You can accept payment in any currency but can only clear in major currencies but only if this has been agreed with your Bank.
Bank sort code : This is the sort code for the Bank Account to which your transactions will be cleared.
Bank account number : This is the Bank Account Number to which your transactions will be cleared.
PROVIDERS - if details known yet
Card Services Provider :  
Payment Currency : Do not modify this value without prior arrangement with SECPay
Merchant Number :
Do not put in you standard merchant number.		 This is the number issued to you by the acquiring bank for your Internet transactions. Do not put in you standard merchant number.
Clearance Merchant Number : Required for HSBC Credit Card (not Switch) providers only. In fact it is the Switch merchant_no!
PAYMENT METHOD
Payment Type :

Please debit my card
£58.75p

If paying by Cheque please make your cheque payable to SECPay Ltd.

 Enter your card number and expiry date below.

Expiry date ./

Select how you would like to pay for your registration by credit card or by attaching a cheque with your signed registration form. 

Select your TARIFF       

Note you may switch tariffs at the end of a billing month by giving us 5 days notice. New rates will apply to the following months transactions.

Please print this form, sign and send to SECPay at the address above.

Please note:

SECPay will authorise your card and will automatically debit your account if you have chosen to pay by credit card. This transaction is being carried out over a secure link.

I declare that, as far as I am aware, the above information is correct. I appreciate that this form is not an application to trade with SECPay and must be printed and forwarded by Royal Mail.

I declare that if I have elected to pay by credit card then the same card details can be used as continuous authority by SECPay Limited to clear any invoices or other service charges levied by SECPay in full after 7 days of having received any electronic invoice for any such service.

If I have elected to pay by check then my check will be enclosed with this form and I will pay all future fees promptly and in full when requested by SECPay by electronic or paper Invoice.

I will also undertake to read and understand the SECPay API or engage the services of a technically competent person before interfacing to SECPay or calling the support line. I will report all positive suggestions for the benefit of all SECPay customers to SECPay using the support section of the Web site. In the first instance all issues should be reported via the web site. I understand that use of SECPay support for general technical issues not directly related to interfacing to SECPay will attract consultancy charges.

I understand that SECPay can only hold information on behalf of the merchant that has been supplied by the merchant either directly or via the merchant's Web site. All information gathered by the merchant will be held by the merchant and/or forwarded to SECPay in accordance with the API.

This form must be printed, signed and returned with your setup and connection fee to the address above. Electronic submissions will help to speed up your registration but we still need your signature, this is a legal requirement. It is your responsibility to contact the acquiring bank and to organise an Internet merchant account.

Signature: ______________________________
 
Please print name: ______________________________