EntroPay Authorisation Release Request

EntroPay
Registered Address: 32 Kingly Street, London W1B 5QQ
Incorporated in England and Wales (Reg. No. 4072405)
Certified by the UK Financial Conduct Authority as a Small e-Money Issuer
http://www.fsa.gov.uk/register/eMoney.do

Authorisation Release Request

Merchant Information
Merchant/Business Name
Contact Person
Contact E-mail Address
Merchant ID
Authorisation Information
Customer Name
Full Card Number
Transaction Date
Authorisation Code
Transaction Currency & Amount
Reason for Release

Signature of approval:

NOTE: Any merchant requesting the release of authorised funds prior to the 30 day expiry period
imposed by the VISA Network must complete this form and send the document to
support@entropay.com.

EntroPay is a registered trademark of Ixaris Systems Ltd