Empire ATM Group New Order Configuration

Terminal Deployment Location

Name of Location

Physical Street Address of Location

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Location Phone Number

Business Tax ID Number of Merchant

Type of Business

Merchandise/Services Sold where terminal is deployed

Financial Institution Number (Fl#, FDIC, NCUA, ASI)

Applicant Name

First Last

Email

Company Legal Name as stated on Articles of Incorporation

Company Federal Employer Identification Number (FEIN)

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