Hardware Order Form for Canadian PC PAY
Please make sure to fill in the required fields and submit this form to complete your order.
My Products
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( X )
Link 2500 (CAN)
$
985.00
Quantity
1
2
3
4
5
6
7
8
9
10
Purchase or Lease?
Purchase
Lease (Monthly)
Lane 3000 (CAN)
$
1,130.00
Quantity
1
2
3
4
5
6
7
8
9
10
Purchase or Lease?
Purchase
Lease (Monthly)
Full Name
First Name
Last Name
E-mail
example@example.com
Contact Number
Facility Name
Shipping Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Special Instructions
Submit
Should be Empty: