Allegiant ATM Intake Form
Five Star Representative Intake Form
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Location/Factory
Name of Location *
Street Address *
Street Address Second Line
City *
State *
Zip *
Contact Name and Title *
Contact Phone Number *
Contact Email Address *
Number of Employees *
Is there a credit Union Associated with the location? *
If yes, what is the name?
Does location already have an ATM? *
Required
Select Program *
Required
Five Star Representative
Name *
Phone Number *
Email Address *
In the event an automated teller machine is placed in this location, a commission, in the form a prepaid gift card, will be emailed to the Five Star Representative to the email address provided.
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