Business Name And Dba Change Form - E-Merchant

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Business Name & DBA
Change Form
Important: Please read before proceeding:
*ALL INFORMATION LISTED IS REQUIRED AND MUST BE COMPLETED.
*PLEASE FAX THIS REQUEST FORM TO CUSTOMER SUPPORT 866.453.2060.
*THIS REQUEST WILL NOT BE EFFECTIVE UNTIL THE REQUIRED DOCUMENTS ARE PROVIDED AND
APPROVED.
*MERCHANT MUST MAKE ACCOUNT CHANGES DIRECTLY WITH AMERICAN EXPRESS
(800) 528.5200.
*SOME FEES MAY APPLY.
Merchant Number _______________________________________________
Current DBA:
______________________________________________________
New DBA:
______________________________________________________
Allow 48 Hours before Terminal Receipt reflect new name
Current Legal Name ______________________________________________________
New Legal Name
_________________________________________________________________________________
New Business Type:
Change to LLC
Change to Corporation
Are you selling different products:
Yes
No If yes, describe ____________
Please submit one of the following supporting documents:
Articles of Incorporation
DBA Filing
Name Change Filing
Business Filing
Seller’s Permit
Fictitious Name Filing
Note: A change in ownership or legal status will require a new application.
____________________________________________________
___________
Signature of Authorized Principal (as specified on the Merchant Account Application/Agreement)
DATE
__________________________________________________________________________________________________________________________
PRINT NAME
PHONE
EMAIL
Please direct all questions to Customer Support at 866-979-0260. Fax to 866.453.2060.
OFFICE USE ONLY
BANK ___________________________________________ DATE ___________________
GATEWAY _______________________________________ DATE ___________________

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