New Terminal Form
Desired Date of Activation
MM
/
DD
/
YYYY
ATM Location Information
Location Name
Your answer
Street Address
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Location Contact
Your answer
Telephone
Your answer
Email Address
Your answer
Location Type
Required
ATM Specifications
Equipment
Model
Your answer
Serial Number
Your answer
ATM Telephone or Wireless Serial Number
Your answer
Required
Equipment Compliance
ATM Revenues
IMPORTANT - It is recommended that Payees who are Merchants select the "Monthly Check" Surcharge Settlement below. An ACH Authorization Agreement is required to be sent in with this form for the Vault Cash Account as well as for each "Daily Direct Deposit" Surcharge Settlement Payee chosen below.

***An IRS W-9 Form must be sent in with this Setup Form***

Surcharge Rate $
Your answer
Payee #1
Name
Your answer
Surcharge Allocation ($ Amount)
Your answer
Surcharge Settlement
Payee #2
Name
Your answer
Surcharge Allocation ($ Amount)
Your answer
Surcharge Settlement
Payee #3
Name
Your answer
Surcharge Allocation ($ Amount)
Your answer
Surcharge Settlement
Setup Notes (optional)
Your answer
Authorization
Requested By
Your answer
Disclaimer
By submitting this form "you" the owner, operator of this ATM terminal are responsible for any and all ATM compliance (EMV, ADA, Fee notice, etc.) eGlobal will not be held responsible for any fees, fines or litigation brought on by failing to adhere to Network, Processor and Government regulations
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