* Required
APPLICATION FOR DINERS CLUB MERCHANT ACCOUNT
Please select the option that best describes you:
Distribution of your Business
One Location            Multiple Locations           Franchise Locations
The Person who completes the application certifies that he is an authorized person to apply for the service on behalf of the firm.
Name of Business or Company Name  *
Address *          P O Box *         City *
Telephone *         Fax 
Email Address  
Business Incorporated ?  Yes  No            If Yes CR Number 
What products & services do you offer *
Travel Agents ?    IATA Number
Total Annual Sales (all payment types) *
Please select a specific description for your Business  
Authorized Signer's Name *        Title *
Have you previously accepted, or are you associated with any other business that currently accept Diners Club Cards 
Yes  No
If Yes, please provide the Diners Club Merchant Number 
Bank Name *         Branch 
Account Number