Bersian Merchant Application

Company Name ^*

Company Registration No. ^*

Website / Social Page^*

Address ^*

City ^*

Postcode ^*

State ^*

For crediting of sales purposes.

Please note that Bank Account Name must be the same as above Company Name

Bank Account Name ^*

Bank ^*

Bank Account Number ^*

I hereby undertake that I am authorised to apply for this merchant account, and agree to all Terms and Conditions related to this account application.