Access Request Form: Request for a copy of Personal Data under “Data Protection Legislation” means the EU General Data Protection Regulation (GDPR) 2016/679 and any applicable legislation or regulations that implement the GDPR into national law in addition to any other applicable law or regulation relating to the processing of personal data and to privacy, as such legislation shall be amended, revised or replaced from time to time

This form is for the use of Gateway Merchants Services Limited trading as PaymentPlus and its subsidiaries only.

Important: A fee of €6.35 and copy of photo identification and recent proof of address must accompany this Access Request Form (see Note below).

Section A - please complete this section :

Full Name…………………………………………………………….

Postal address:

…………………………………………………………………………

Telephone*…………………………………………(include area code) and e-mail* …………………………..…………………………….

* we may need to contact you to discuss your Access Request

Section B - please complete this section :

I, …………………………………………………..[insert name] wish to have access to data that I believe PaymentPlus retains on me as outlined below, please include the name of service(s) and any account / reference number relevant to your access request: ………………………………………………………………………..……………………………………… Reason for request:

………………………………………………………………………..……………………………………… …………………………………………..

…………………………………………………………………………………..…………………………… …………………………………………..

…………………………………………..

Signed…………………………………………….. Date……/………/………. …………………………………………..

Checklist: Have you:	Yes	No
1) completed the Access Request Form in full?
2) included a cheque or postal order made payable to PaymentPlus in the amount of €6.35?
3) provided a copy of photo identification and recent proof of address?
4) signed and dated the Access Request Form?

If you have ticked No to any question above we regret we cannot process your request.

Please return this form to: The Customer Services Department, PaymentPlus, at Unit F2 Nutgrove Office Park, Rathfarnham, Dublin 14.

Office Use only:

Real email address is required to social networks

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