Restaurant Delivery Platform Merchant Account Status Evaluation Form

Merchant/Store Legal Name

Platform Name

Merchant/Store ID or Account Reference

Store Location Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Current Account Status

Reason for Status Evaluation

Primary Issue Category

Brief Description of Issue

Incident or Review Period

Date

Hour MinutesAM/PM Option

Supporting Evidence / Notes

Full Name

First NameMiddle NameLast Name

Role / Title

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Preferred Contact Method