Applicable For Nayara Energy Only

Merchant Processing Application Form

New Application Additional MID Additional TID

MCC – 5541 Fuel Station CMSCODE

Existing IMS MID Super MID No.

“Doing Business as Name” (DBA) Legal Name

(Only Applicable for Additional MID) (Only Applicable for Additional MID)
Title Mr Mrs Miss Ms Dr Title Mr Mrs Miss Ms Dr
First Name Middle Name First Name Middle Name

Surname Surname

Position Owner Partner Director Employee Others Position Owner Partner Director Employee Others
Date of Birth d d m m y y y y Date of Birth d d m m y y y y
Mobile Phone Number Mobile Phone Number

PAN No./Aadhaar No./DL No. PAN No./Aadhaar No./DL No.

Fees
1) The MDR (merchant service fee) would be applicable and charged as per scheme/RBI guidelines and is subject to revision. Also, in case of any scheme/RBI
or any regulatory charges as per the Agreement that charges would be borne by You.
2) Wherever only International value is given, all other card types will be updated as same value.

C P I A
MSF (Transaction Charges)
D IC INC

I / We agree to inform ICICI Merchant Services immediately if I / We wish to discontinue transacting using the Point of Sale terminal (‘POS Terminal’) provided
by ICICI Merchant Services.

For each item of Supplied Equipment that you fail to return to ICICI Merchant Services in accordance with the above terms or Supplied Equipment is not operative

I / We have read and agreed to the above mentioned fees.

Merchant seal & signature

I would not like to receive promotions and special offers on mobile / statement by email.
 MOST IMPORTANT TERMS AND CONDITIONS
The Most Important Terms and Conditions (MITCs) mentioned hereinbelow are to be read and understood in conjunction with the Merchant Processing
Application Form as executed by you in favour of ICICI Bank Limited (“ICICI”) and ICICI Merchant Services Pvt. Ltd. (“ICICI Merchant Services”)
(“Application”) and the Transaction Documents, which is comprised of the Application, the Privacy Statement and Consent, the General Terms (which
includes the E-Com Terms and the Other Payment Method (OPM) Terms) and the Operating Guide (“Transaction Documents”) for receiving payment
processing facilities and services (“Services”). The General Terms including the Privacy Statement and Consent and the Operating Guide are given on
https://merchants.fiserv.com/content/dam/firstdata/india/en/pdf/IMS-General-Terms-Nayara_IMS-Legal-Updated_Nov-3-2020.pdf In the
the link [https://merchants.fiserv.com/content/dam/firstdata/india/en/pdf/IMS-General-Terms-Nayara_IMS-Legal-Updated_Nov-3-2020.pdf].
event of a conflict between any of these MITCs and the Transaction Documents, the Transaction Documents shall prevail.

1. Transaction Procedures: You must follow all procedures and requirements relating to 8. Security: ICICI Merchant Services and /or ICICI may from time to time request
security from you or a guarantor to secure performance of your obligations under
the Transaction Documents. You agree to do all things necessary to put in place
Transaction Records: enforceable security as requested by ICICI Merchant Services and/or ICICI as laid
down under the Transaction Documents.
relating to any Card transactions when ICICI Merchant Services requests them. 9. Financial and Other Information:
3. Compliance of Data Security Standards: You shall comply with provisions contained
concerning your business as we request to assist us with our continuing

immediately of any change in circumstances affecting your business including

Your Information:

connection with our determination whether to accept the Transaction Documents

our privacy collection statements and privacy policies. We will implement all data
4. Fees:

ICICI Merchant Services and ICICI (and our respective related bodies corporate
which may be located inside India) in connection with the terms of the Transaction
Documents and in accordance with our privacy collection statements and privacy
Services deduct those amounts from the amounts payable to you under the
Transaction Documents and you provide your express consent and authorisation to information from your Application between ICICI and ICICI Merchant Services
ICICI to honor such directions given by ICICI Merchant Services to ICICI. You agree to

against ICICI for such deduction. You agree to reimburse ICICI Merchant Services for (which may be located overseas) as relevant to the transaction.
the amount of any charges it incurs as a result of any debit to the Settlement Account

well as any additional fees or pricing set out in the Transaction Documents. Those fees entities (which may be located inside India). (f) You irrevocably authorise us to
are payable when the services are provided. discharge and/or release to the relevant Card Schemes all or any of the documents
(including but not limited to the form and the content of the Transaction
5. Chargebacks and Other Liabilities:
from time to time or at any time you disclose or release to us and/or we may

or more of us either directly or indirectly arising out of: (i) a Card transaction between transaction contemplated in this Transaction Documents and/or in relation to or in
you and any Cardholder; (ii) all Card transactions you submit that are charged connection with the Transaction Documents; and/or which an Card Schemes may
lawfully require us to provide to it from time to time or at any time.
requested by us within the applicable time limits; (iv) you or any of your Employees
11. Return of Equipment: For each item of Supplied Equipment that you fail to return
wilful misconduct or fraud by you or your Employees; (vi) any dispute over goods or to ICICI Merchant Services in accordance with the above terms or Supplied
services between you and a Cardholder; (vii) any warranty representation whatsoever Equipment is not operative due to physical damage (except minor damages
in relation to any goods or services supplied by you; (viii) your failure to comply with which does not cause Supplied Equipment non-operative/non-functional) or the
any of your obligations under the terms of the Transaction Documents; terminal is not returned to ICICI Merchant Services, you must pay ICICI Merchant
Services the greater of Rs. 15,000 or the fair market value of such item of Supplied
of the Services; (x) any losses suffered by either of us as a result of that one of us Equipment had it been returned to ICICI Merchant Services in appropriate
indemnifying the other for your failures to meet your obligations under the terms of condition (charges not applicable if covered under insurance). Alternatively,
ICICI Merchant Services may retrieve the Equipment from you and you authorise
ICICI Merchant Services to access your premises for that purpose. Additionally,
charges of Rs. 500 for tampered SIM, physical damage/ loss of SIM and Rs. 1,200
balances lying in any account that You hold with ICICI towards the satisfaction of for tampered adapter, physical loss/ damage of adapter will be applicable.
Your liability under the terms of the Transaction Documents. ICICI are entitled without No Transaction Charges to be levied on Cardholders: Pursuant to Circular Nos:
any notice to you to settle any indebtedness whatsoever owed by you to ICICI and/

transactions done by Cardholders at POS terminals. In this regard You also agree
Debits and set off: ICICI shall itself or at the instruction of ICICI Merchant Services as
relevant may reserve the right to: (a) debit your Settlement Account and/or (b) deduct
and set off from settlement funds due to you; and/or (c) invoice/raise a debit note to

or in relation to the terms of the Transaction Documents. time to time and an Other Payment Method (or OPM) means the services offered
7. Interest: by ICICI Merchant Services to provide Merchant with the ability to accept payments

I/We agree to inform ICICI Merchant Services immediately if I/We wish to discontinue transacting using the Point of Sale Terminal (POS terminal) provided by
ICICI merchant services.

Merchant seal & signature

I would not like to receive promotions and special offers on mobile/statement by email.
 Contact Us
In case you have any query or issues related to our services,
please call our 24 x 7 toll free Customer Care number on
1-800-266-6545/1-800-102-1671
For any query or issues regarding our Internet Payment Gateway please
call our 24 x 7 toll free Customer Care number on 1-800-102-1673
You may reach us via email on [email protected]
You may also write to us with your contact details at ICICI Merchant Services

Level 1 : Escalation Desk

Nodal Desk
Email ID: [email protected]
Phone: 022-41634032

Level 3 : Business Head