This form is for USA merchants and business owners only
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This is a form for businesses located in the USA that are interested in purchasing an ATM or for
business owners wanting an ATM placed at their location. .
Please fill out all fields as best you can then click on Submit at the bottom of the page when ready to send.
All information is kept strictly confidential.

First, the person who is filling out this form is:

Form Submitted By:
Choose one:
Email address:




Please fill out all questions.
Please list a phone number for us to contact you.
We appreciate your interest in our company!

1. How many ATMs are you interested in?
2 ATMs
3 ATMs
4+ ATMs
I do not need an ATM at this time. I need ATM processing for my ATM.

2. How many people come into your business each day.

3. What models of ATM are your interested in? Use your control key to select more than one

4. What type of business do you operate where you want to put this ATM?

(if other please specify): 

6. Are you interested in buying, leasing to own, or having an ATM placed at your business?
Lease to Own
ATM Placement
Other (please specify): 

8. How soon do you want an ATM?

Anything else you would like to tell us or comment on? When is the best time to contact you?

Personal contact information, or business location information:
Name of Business 
Owner's Name
Business Street Address
City    State   Zip
Preferred phone number we can reach you at

Please allow a few seconds for the form to be processed and sent.
Thanks for taking the time to fill out our form.