Company Address:

Please provide us with the name(s) of the person(s) who should be contacted with all matters and issues related to online access to your account. The Primary Contact will be designated as the person who will manage your organization’s access to your account. They will be responsible for adding and deleting users as well as assigning each user their relevant rights to the Online Portal. For Credit Card Payment access, please check the box if applicable.
CC Payment Access
Primary Contact:
CC Payment Access
Secondary Contact:

I/We understand that our organization is responsible for all transactions entered via the Online Portal by our designated representatives and any relevant charges incurred will be subject to the terms and conditions of the Charge Customer Agreement.
Name of Authorized Representative:
MM slash DD slash YYYY