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Equipment Order Form
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Deployment Form
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Wireless Agreement
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ISO & Agent Equipment Order Form
NEW
REDEPLOYMENT ($50)
REPROGRAM ($50)
Application Type
Agent Company Name:
Date:
Agent Name:
Agent ID#:
Phone #:
MERCHANT CONTACT INFORMATION
Legal Business Name:
Phone #:
Onsite Merchant Contact:
E-mail:
MOBILESCAPE RECEIPT HEADER INFORMATION
**Note: If a logo is provided for the receipt header, the company name will not appear on the receipt.**
Merchant DBA Name:
Logo (Y/N)
($50 fee)
Merchant Address:
Phone #:
City:
State:
Zip:
Website Address:
BILLING INFORMATION
Leasing Company Name:
Split Funded
Name on Card:
Card Type
(Visa/MC/AMEX)
Credit Card #:
Exp:
CCV2:
Billing Address:
City:
State:
Zip:
SHIPPING INFORMATION
Business Name:
Attention:
Address:
Phone #:
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 additional UPS fee)
PRICING
Mobilescape Terminals
Price
Quantity
Total
Mobilescape 3000 Credit Card Unit
Mobilescape 5000 Check/Credit Unit
Accessories
Mobilescape Car Charger
Mobilescape Carrying Case
Mobilescape Protective Skin
Mobilescape Styluses (5 per pack)
Mobilescape Thermal Paper (25 rolls/per bx)
Mobilescape Wall Charger
Signal Strength Enhancer
Total Shipping Cost*
(via UPS) -
place an
x
next to the selected delivery method
Ground
Sub Total
2nd Day Air
Shipping/Handling Fee
Next Day Air Saver (typically by 3:00 pm)
Total
Next Day Air (typically by 10:30 am)
Saturday Delivery
3rd Party/Local Pickup (handling fee only)
3rd Party Company, Account # and Method
*Once the shipping zip code, terminal and accessory quantities are entered, the shipping/handling cost will be calculated.
SPECIAL INSTRUCTIONS
Fax completed application to 713-735-5503 for processing.
Questions? Contact Cale at 713-735-5538 or Roy at 713-735-5532
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Equipment Order Form
|
Deployment Form
|
Wireless Agreement
|
ISO & Agent Deployment Form
Merchant Name:
Date:
ISO/Agent Name:
Agent ID#:
Phone #:
APPLICATION TYPE
Mobilescape 3000
Mobilescape 5000
Select all terminal functions that apply
Cash
Invoice
Tip*
Memo
InstallmentPay
Custom Memo
*The tip function is only available on credit card & cash transactions
PROCESSING NETWORK SETUP
Terminal Type: TPI Software
FDR North (Cardnet-retail)
MID:
TID:
DID:
Chase Paymentech (Net Connect platform only/terminal capture)
PNS MID:
TID:
Client ID:
Net Connect User ID:
Net Connect P/W:
Vital/Visanet (terminal type stage only)
Parameter Sheet Attached:
MID:
Bus. Area Code:
Terminal #:
Bus. Phone:
Agent #:
ZIP Code:
Chain:
Category Code:
Store #:
Terminal ID/V number:
BIN:
Terminal Type: eProcessing Software
FDR Nashville (product 0207-retail/terminal capture)
MID:
TID:
FDR Omaha (ETC 7-retail)
MID:
(13-16 digits)
Date Issued:
Global East (EK2-retail/terminal capture)
Bank ID:
TID:
Category Code:
Elavon (via conex-retail/terminal capture)
Bank ID:
TID:
CHECK PROCESSING
Check Processor:
Check Conversion MID:
Check Verification MID:
Fax completed application to 713-735-5503 for processing.
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Equipment Order Form
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Deployment Form
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Wireless Agreement
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MERCHANT WIRELESS SERVICE AGREEMENT
Agent Name:
Agent ID:
Merchant Name:
Address:
City:
State:
Zip:
Phone Number(s):
Merchant E-mail Address:
Merchant ID:
Processing Network:
FDR
Vital
Global
Chase Paymentech
Elavon
I/we hereby authorize BankServ to ACH Debit my/our bank account indicated below at the depository financial institution named below on the first business day of each month in payment for the following fees plus applicable taxes.
Monthly Wireless Subscription Fee
(per terminal)
Per-Transaction Fee
Next-Day Replacement (NDR) Program
(per terminal)
This authorization is to remain in full force and effect until BankServ has received written notification from me (or either of us) of its termination in such time and in such manner as to afford BankServ and the depository financial institution named below a reasonable opportunity to act on it.
Please attach a voided check.
Depository Name:
Branch:
City:
State:
Zip:
Routing Number:
Account Number:
I/we acknowledge that the origination of ACH transactions to my/our account must comply with the provisions of U.S. law , and that I understand that these fees are in addition to fees incurred by the merchant account bank.
Name(s):
ID: Number:
(Please print, must be the same as signer(s) on merchant agreement)
(Federal Tax ID or SSN)
Date:
Signature:
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