Notification of Intent to Surcharge

Business Information

Account Number is required Account Number*
Business Name Business Name*
Address is required Address*
City is required City*
Province*
Select... Alberta British Columbia Manitoba New Bunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
Postal Code is required Postal Code*

Notification Submitter Information

First Name is required First Name*
Last Name is required Last Name*
Email Address is required Email Address*
Job Title is required Job Title*
Phone Number is required Phone Number*

Confirmation

Without in anyway limiting Merchant’s obligations to comply with the Payment Brand Rules and its other obligations under the Merchant Agreement, including the specific rules and requirements relating to surcharging, Merchant confirms as follows:

Notification of intent to Surcharge

Checkbox is required Merchant confirms its intent to assess a surcharge on credit card transactions, as of a date no sooner than 30 days from the date of submission of this confirmation.*required

Checkbox is required Merchant acknowledges that a surcharge may not be assessed on debit or prepaid Cards. Merchant further confirms that its Surcharge will not exceed the lesser of (i) Visa and Mastercard’s mandated maximum (currently 2.4%) and (ii) its average merchant discount rate that Merchant pays for credit card acceptance.** *required

Checkbox is required Merchant confirms that if it accepts credit card brands such as American Express or PayPal, there are requirements around the circumstances in which a Merchant can surcharge, depending on the costs of those brands and those brands’ surcharging restrictions. Please see Visa and Mastercard rules for details.*required

Credit Card Surcharge Disclosure Requirements

Checkbox is required Merchant acknowledges its obligation to clearly and prominently disclose, both at the point of entry into its place of business and at the point of sale, any Surcharge that will be assessed. For Merchant’s e-commerce channel, this disclosure will be displayed on its web page prior to checkout, allowing the cardholder to cancel the transaction before completion. In a telephone order transaction, verbal notice will be provided to the cardholder, including clearly setting out the surcharge amount.*required

Checkbox is required Merchant acknowledges that its disclosure will include all of the following:*required

• The exact amount or percentage of the surcharge
• A statement that the surcharge is being assessed by the merchant and is only applicable to credit card transactions
• A statement that the surcharge amount is not greater than the lesser of (1) the surcharge cap, currently 2.4%; and (2) the average merchant discount rate that Merchant pays for credit card acceptance**