Enter the date of order... :

-- mm/dd/yy

Enter the time of order... :

-- hh:mm:ss am/pm

Please provide the following contact information:

Merchant Name
Merchant #
MUD/ESO#
Sale Rep Name
Email
Contact Phone #

Form Of Payment {Must Accompany Order}.

What type of credit card is being used?

MCVisa Amex Discover

Lease?

Yes No

 

 

If yes name if Leasing Company:

COD? Add Extra $10 to Total - Cashiers Check or Money Order Only

Yes No

Equipment Requested*

QTY	DESCRIPTION

	SHIPPING
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

Programmed?

Yes No

Special Instructions:

Front End:

FDR/ETC
BUYPASS
VISA NET (VITAL)
WIRELESS (allow five (5) business days)

Application:

Retail
Restaurant
Hotel
Debit
AVS
EBT (allow six (6) Business days)
EZCheck

Other: