Online Access Request Form

Tara Account No.:

Company Name:

Company Address:

Street Address Address Line 2 City Parish Postal Code

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

Yes

Primary Contact:

First Last

Phone (O)

Phone (M)

CC Payment Access

Yes

Secondary Contact:

First Last

Phone (O)

Phone (M)

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:

First Last

Date

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