Name:___________________________________________________________
Address: _________________________________________________________
City: ___________________________________________________________
State/Province: _____________________Zip/Postal Code: ________________
Phone: (_____)________________________ Fax: (_____)_________________
Contact Name: ____________________________________________________
Contact Phone: (_____)_____________________________________________
Contact Email: _____________________________________________________
Country Code [3]: ___________________________________________________
City Code or Zip Code [5]: ____________________________________________
First 12 digits of NSI Terminal ID [12]: ____________________________________
Remaining digits of NSI Terminal ID [9 max]: ______________________________
Merchant # [15]: _____________________________________________________
AMX Terminal ID [21 max]: ____________________________________________
Terminal # [2]: ______________________________________________________
Location # [4]: ______________________________________________________
Type [4]: ___________________________________________________________
First 6 digits of Serial # [6]: _____________________________________________
Remaining digits of Serial # [4 max]: ______________________________________
Primary Authorization Phone: (_____)_____________________________________
Alternate Authorization Phone: (_____)____________________________________
Primary Settlement Phone: (_____)_______________________________________
Alternate Settlement Phone: (_____)______________________________________