equipmentOrderFormv 072710 by M5wrJ5

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									                                                                TransFirst Equipment Order Form
                                                      371 Centennial Parkway  Louisville  CO  80027
                                                  FAX 303-482-8194  SalesResponseTeam@TransFirst.com
                                                         REQUESTOR INFORMATION
   STW                             Name of Requester                                                      Today’s Date
                         No Mark Up                Mark Up                           Bulk Orders:      Bill Merchant           Bill STW      (Override the Price)
   Bill STW                                          N /A                            Bill TransFirst                           (TF Manager Approval via Email)
   Bill Merchant                                            (Create Charge Record)   Leasing                     Yes                 No      (Always Bill the MID)
   Direct / Partnership           (Always Bill the MID)
                                                                                       Priority Overnight     Standard Overnight      Saturday Delivery
   Ship To                        Merchant          STW            Other               2nd day    Ground
   Merchant DBA                                                                      MID

   Shipping Address                                                                  Shipping City

   Shipping State                                                                    Shipping Zip
                                                                                     Shipping Contact
   Shipping Phone #
                                                                                     Name
   Shipping Notes

                     WIRELESS ORDERS MUST BE RECEIVED BY 11 AM MST TO SHIP SAME DAY. ALL OTHERS BY 2 PM

                                    **** PLEASE COMPLETE QUANTITY AND PURCHASE PRICE ****
    QTY                   EQUIPMENT                   NEW        REFB       RENT      QTY                 EQUIPMENT                  NEW       RERB        RENT

                                     TERMINALS                                                                         ADAPTERS
              VeriFone Omni vx510 (3730)                                                       Omni 3750/3740 Dual Comm.
                                                                                                                                                 N/A        N/A
              (Cash Advance Only)                                                              Module
              VeriFone Omni vx510LE
                                                                                               Nurit 8020 External Modem                         N/A        N/A
              ( 3730LE)
              VeriFone Omni vx570 – Dial                                                       Nurit 8020 Additional Battery                     N/A        N/A
              VeriFone Omni vx570 – IP                                                         Nurit 8000 External Modem                         N/A        N/A
              Hypercom T7Plus (Thermal)                                                        Nurit 8000 Additional Battery                     N/A        N/A
              Hypercom T7Plus 2MG
                                                                                                                       PIN PADS
              (Petro Partner Only)
              Lipman Nurit 8020 GPRS                                                           1000 SE-Vital/PNS
              WAY Systems MTT 1581                                N/A        N/A               Hypercom P1300 – Vital
              Way Systems MTT 5000                                N/A        N/A                          CHECK READERS AND IMAGERS
              Hypercom T4205                                      N/A        N/A               Magtek Check Reader                               N/A        N/A
              Hypercom T4220 – Dial                               N/A        N/A               Ingenico 2500 Check Reader                        N/A        N/A
              Hypercom T4220 – IP                                 N/A        N/A               Ingenico 2600 Check Imager             N/A
              VeriFone Omni 3750 (Petro Only)             N/A                                  RDM 6014i Check Imager                            N/A
              Hypercom T7P (Lodging Only)                 N/A                                             PC PRODUCTS/ACCESSORIES
              Hypercom T7Plus (Lodging Only)                                                   Pay@PC (Software Only)                            N/A        N/A
              Imprinter – Small                                   N/A        N/A               Semtek Card Reader USB                            N/A        N/A
              Imprinter – Large                                   N/A        N/A               Semtek Card Reader Serial Port                    N/A        N/A
                                      PRINTERS                                                 Pocket Spectrum                                   N/A        N/A
              VeriFone 900                                        N/A        N/A               Pocket Merchant                                   N/A        N/A
              WAY Infrared Printer S-40                           N/A        N/A                         CONTACTLESS CARD READERS
              WAY Infrared Printer MP100                          N/A        N/A               VIVOtech VIVOpay 4000                             N/A        N/A
              P-250 (Pay@PC Only)                         N/A
                                   TERMINAL INFORMATION                                                          MISCELLANEOUS
   Terminal ID:
   Terminal Type:


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