Equipment Order Form

Equipment Order Form
Email
example@example.com
BILL TO
Business Name
Contact Person
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone*
SHIP TO
Shipping to Billing Address?

YesNo
Business Name*
Contact Person*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone*
ATM Equipment Options
Which ATM would you like to purchase?*
ATM Make/Model
How many ATMs?*
ATM Model Type Unit Price
ATM Price Total
Purchase Qty Ordered
Lease Qty Ordered
Equipment Cost Total
ATM Installation Options
ATM Installation Options Pricing:
- Professional Installation, Programming & Training: Includes bolting ATM to merchant floor by insured professional equipped with required tools, custom atm programming, and training on use - $350
- Self Install with Step-By-Step Programming Instructions, & Support Assistance: Self install with detailed step-by-step programming instructions and telephone support assistance - $97
- ATM Manufacturer Pre-Programming: Custom atm programming by the manufacturer with TID, Master Keys and all settings prior to shipping
  Genmega - $150
  Hyosung - $100
Choose Your ATM Installation Option: (Required for New IADs)*

Professional Installation, Programming & TrainingSelf Install w/ Step-By-Step Programming InstructionsATM Manufacturer Pre-Programming
Professional Install, Programming & Training: How many do you need?
Self Install w/ Step-By-Step Programming Instructions: How many do you need?
ATM Manufacturer Pre-Programming: How many do you need?
Installation Cost Total
Self Install Cost Total
ATM Pre-Programmed Cost Total
Payment / Billing Information

For security reasons, you will be required to text a photo copy of your credit card. See below for details.
Name on CC*

First NameLast Name
Same as Bill To AddressSame as Ship To AddressDifferent Address
Billing Address*

Street Address

Street Address Line 2

CityState

Zip Code
EP #1
EP #2
EP #3
EP #4
EP Date
EP Code
For Security purposes, I agree to text a photo of the front and back of my credit card to ATMDepot at 760-512-4124 which will only be used as payment for this Equipment Order prior to shipping or, if I'm unable to text a photo I understand I may provide my credit card info over the phone during the order confirmation call with my IAD account rep.*

I Agree
Any Additional Notes?
Signature*

Clear
Date*

MonthDayYear
Should be Empty:

Equipment Order Form

BILL TO

SHIP TO

ATM Equipment Options

ATM Installation Options

Payment / Billing Information