Cashless ATM Application
PIN Debit Form
Sales Organization or Sales Representative's Full Name
LOCATION INFORMATION
Business Legal Name
*
DBA Name
*
DBA Phone
*
DBA Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Name
*
First Name
Last Name
Phone
*
Please enter a valid phone number.
Portal Login Email Address
*
Enable Tips?
*
Yes
No
Auto Close Time
*
Please Select
5 PM
6 PM
7 PM
8 PM
9 PM
10 PM
11 PM
(IF YOU HAVE MULTIPLE CLOSING TIMES, SELECT THE LATEST OPTION)
Surcharge to Customer
$3.5
Select QTY Terminal WiFi & Cellular
Please Select
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$350.00 PER TERMINAL
Select QTY Terminal Sim Card & Activation
Please Select
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$50.00 PER SIM CARD & ACTIVATION & $15.00 PER MONTH
Select QTY Terminal Mobile Docking Stations w/Charging
Please Select
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$30.00 PER MOBILE DOCKING STATION
Select QTY Terminal Mobile Docking Stations w/Charging
Please Select
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$30.00 PER MOBILE DOCKING STATION
Please Include a Voided Check or Bank Letter
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please Include a Completed & Signed W9
*
Browse Files
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Choose a file
Cancel
of
Please Include a Copy of Cannabis License
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please Include a Copy of Drivers License or ID
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Shipping Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Shipping Speed
*
Ground
2 Day
Overnight
Special Instructions
Submit
Should be Empty: