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ATM Placement Application Form

First Name

Last Name

Title

Address

City

State

Postal code

Phone *

Email *

Business Name *

EIN Number (Tax ID)

Type of Business

Convenience Store with Gas
Convenience Store (no gas)
Liquor Store
Grocery Store
Smoke Shop
Other
Pawn Shop
Supermarket
Dollar Store
Thrift Shop
Hotel
Bowling Ally
Shipping Store (UPS/FedEx/USPS)
Pharmacy
Shopping Mall
Auto / Hardware Store
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ATM Location Information

ATM will be Installed at:

ATM Location Address

ATM Location City

ATM Location State

ATM Location Zip Code

ATM Location Phone Number

Banking Information

Bank Account Name *

Name of Bank

Bank Street Address

Bank City

Bank State

Bank Zip Code

Account Number *

Verify Account Number *

Routing Number *

Account Is Used For: *

Vaulting Only

Commissions & Payments Only

Vaulting, Commissions & Payments

Type Of Account *

Checking

Savings

Surcharge Amount

Merchant Share of Surcharge

My ATM Guys Processing Fee

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

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