What is the current 12 digit MID for your in store processing? (begins with 323):
What is the Legal name of your business?
Store #:
What is your Doing Business As (DBA) name?
What is the business phone number?
Email Address:
What is the business address? Street:
City:
State:
Zip:
Where should PAX device be delivered? Street:
City:
State:
Zip:
Quantity of PAX S300 Devices @ $300.00 a unit & cables: Platform: Nashville)
Bill Account Directly: $10.00 per injection key -- $45.00 for deployment
Invoice

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PAX S300 Request Form

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