FortisPay Equipment Order Form
Please complete contact information for the person placing the order.
* Required
Email address
*
Your email
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
*
Choose
PAX S300 ($274.00) *Plus cost of cabling & power supplies
Ingenico iPP320 ($331.20)
Ingenico iPP350 ($418.80)
Ingenico iSC250 ($533.50)
Ingenico iWL 220/222 ($555.50)
Ingenico iWL 250/255 ($555.50)
Ingenico ISMP4 ($658.90)
Quantity
*
Choose
1
2
3
4
5
6
7
8
9
10
Shipping Information
Shipping costs below are for 1-5 units. Shipping rates may change if additional units are ordered.
Preferred Shipping Method
*
Choose
Ground - $15
2nd Day (no weekend deliveries) - $20
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
*
I agree to have my bank account on file debited upon shipment
Required
A copy of your responses will be emailed to the address you provided.
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