FortisPay Equipment Order Form
Please complete contact information for the person placing the order.
Email address *
Contact Information
First Name *
Your answer
Last Name *
Your answer
Legal Business Name *
Your answer
DBA Business Name *
Your answer
Phone Number *
Your answer
Order Information
Make and Model *
Quantity *
Shipping Information
Shipping costs below are for 1-5 units. Shipping rates may change if additional units are ordered.
Preferred Shipping Method *
Shipping Address *
Your answer
Shipping City *
Your answer
Shipping State *
Your answer
Shipping Zip *
Your answer
Payment
Please check the box below to confirm:
Debit my bank account on file *
Required
A copy of your responses will be emailed to the address you provided.
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