If you would like to get straight down to business and would like to be issued with a contract with Realex Payments, please complete the form below and weíll send you a contract.

Company Details:

* Corporate Name:

* Address:

* Website Address:

Contact Details:

* Main Contact Name:

* Main Contact Email Address:

* Main Contact Phone Number:

* Billing Contact Name:

* Billing Contact Email Address:

* Billing Contact Phone Number:

* Technical Contact Name:

* Technical Contact Email Address:

* Technical Contact Phone Number:

Acquiring Bank:

* Acquiring Bank Name:

Acquiring Bank Contact (if known):

Merchant ID (if known):

Card Types covered under

VISA

Laser

Merchant Services Agreement:

Mastercard

Diners

Currencies covered under

US Dollars $

STG Pound £

Merchant Services Agreement:

Euro €