Payment Credentials Request Form¶
Exigo Payments, Inc.
Payment Credentials Request Form
Payment Credentials Request Form
1. AUTHORIZATION
I authorize Exigo Payments, Inc. to issue payment credentials to the person(s) listed below.
Furthermore, the individual signing below represents that such individual has the authority to bind
Client to this Agreement.
2. NAME AND CONTACT INFORMATION OF PERSON(S) TO RECEIVE PAYMENT CREDENTIALS.
Name:
_________________________________
Title:
_________________________________
Phone Number: _________________________________
Email:
_________________________________
Name:
_________________________________
Title:
_________________________________
Phone Number: _________________________________
Email:
_________________________________
Approved by:
_________________________________
Title:
_________________________________
Phone Number: _________________________________
Email:
_________________________________
Date:
_________________________________
After completion, please return to Jay Boyer at jayb@exigo.com. Once we have received this form,
payment credentials will be provided to the above.