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Type of ATM Service Requested (Please Check All That Apply)
Free ATM Machine PlacementBuy ATM ProgramsLease ATM ProgramsSpecial Event ATMATM Transaction ProcessingTriple DES Upgrade & Triple DES EncryptionATM Advertising

Type of Location (required)

Estimated Number of Daily Visitors

Estimated Number of Daily Foot Traffic in Front of Your Location

Forms of Non-Cash Payment Accepted
ChecksCredit CardsDebit CardsOther forms of "non-cash" payment

Do you currently have any ATM Machines? (required)

What type of ATM Machines are you considering?

Descrive the Area around your location

Please provide us with any other info you feel will help us understand your business environment better, such as an ATM machine right next door, a bank ATM down the street, etc. If you have an ATM, please include your current monthly transaction count.

Additional Comments

Your Information

First Name (required)

Last Name (required)

Your Email (required)

Phone Number

Company Information

Company Name





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