Discover Debit Merchant Referral Form

Complete the short questionnaire below to help us provide the best customer experience.

* These fields are required.

  • Merchant Information

    Was this an online purchase/payment?*

    Name of Merchant Business or website address*

    Was this purchase made on a military base?*


    Street Address


    State / Province*

    Zip / Postal Code

    Phone Number

  • Shopping Experience

    Date of Visit*

    Does the merchant offer Discover as a method of payment?*

    Was the transaction attempted?*

    Transaction amount*

    Time of transaction attempt

    Were you attempting to use a chip card?*

    How was the chip card used with the card terminal?*

    Has the chip card been successfully used with other merchants?

    How was the chip card used with other merchants?

    Back to your original referral, if you used a different card, was the transaction successful at the merchant?

    Was the other card that you used a chip card?

    Please select all that apply about your experience:

    At checkout, did you:*

    Checkout Type Comments

    Was there a pin pad or any place to enter your pin?*

    When you or the cashier swiped/inserted your card, were you prompted or given the following payment options? Please select all that apply.

    What option did you select?*

    After selecting Debit as your payment option, were you prompted to: Please select all that apply.

    If you selected get cash back, were you able to successfully get cash back?*

    What was the message displayed on the terminal/online checkout?

    Was the card previously accepted at this merchant?

  • Debit Card Details

    Issuing Financial Institution*

    Card Product*

    First 6 and Last 4 digits of your card*

    Your card information will be used solely for the improvement of this issue and will not be shared outside of Discover card.

  • Referrer Information


    Confirm Email*

    First Name*

    Last Name*

  • Additional Comments

    Please enter any additional information regarding your experience which may help us resolve this issue

  • Captcha

    Case Sensitive, No Spaces Allowed.

    The information you submit on this page will be used by Discover for internal business purposes and not shared with third parties unless required by law.