Demo Order Form
Agent Name:							Date:
ISO Name:							Agent ID:
Phone #:
APPLICATION TYPE
Mobilescape 3000 Mobilescape 5000				Select all terminal functions that apply							FALSE
					Invoice Tip* Memo						FALSE
					*The tip function is only available on credit card transactions
Name of Check Provider:
MOBILESCAPE RECEIPT HEADER INFORMATION
DBA Name:							Phone #:
Address:
	City:				State:		Zip:
Website Address:
BILLING INFORMATION
Name on Card:						Card Type (Visa/MC/AMEX)
Credit Card #:						Exp:		CCV2:
Billing Address:
	City:				State:		Zip:
SHIP TO
Business Name:							Phone #:
Address:							Attention:
	City:				State:		Zip:
Is this a residential shipping address? (Y/N)						($4.50 additional UPS fee - signature required)
Would you like Saturday delivery? (Y/N)						($15.00 additional UPS fee)
PRICE
Demo Terminal* -place an x next to the selected terminal, subscription fee and delivery method
	Mobilescape 3000 (credit card ) - $399.00
	Mobilescape 5000 (check/credit card) - $399.00
*Each terminal comes with a stylus, wall charger and 3 rolls of paper
Monthly Wireless Subscription Fee
	$10.00 per month
	$100.00 annual
Total Shipping Cost** (via UPS)
	Ground							Sub Total
	2nd Day Air					Shipping/Handling Fee
	Next Day Air Saver (typically by 3:00)							Total
	Next Day Air (typically by 10:30 am)
	Saturday Delivery
	3rd Party/Local Pickup				3rd Party Company, Account # and Method
	(handling fee only)
**Once the shipping zip code and terminal have been selected, the shipping/handling cost will be calculated.
SPECIAL INSTRUCTIONS
Print and fax to 713-735-5503   Questions? Contact Roy at 713-735-5532