OTC Equipment Upgrade Form

BUSINESS INFORMATION

We are excited to upgrade your terminal for InComm Payments NEW TRNSX platform.

Please fill out all the data below and ALL fields with an * asterisk are required and must be completed to submit your request.

Company Legal Name

Name company is registered with the state

DBA Name (Doing Business As)

Business Name on the building

Business Phone

ex: 111-111-1111

Business Email

Mobile Phone number is required to receive a one-time password once the Terminal or Web Access is received.

Mobile Phone

ex: 111-111-1111

Total percentage of State and Local Sales Tax (Ex 8 %)

This is used to configure terminal for transaction purposes.

Verify the Last Four Digits of the bank account information InComm has on file you get reimbursed for your OTC transactions.

NEW TERMINAL DEVICE OPTIONS (SELECT ONE)

Equipment selection is Required

WiFi (Portable Wireless Connection - Device has a built in scanner)

Wired Network Connection (This terminal will have both Wi-Fi and an ethernet port for a wired connection and includes a USB laser barcode scanner. This terminal must be plugged into a power source to operate.)

Web Application ONLY (NO equipment provided by InComm) (Merchants who use equipment that allows them to access a web browser are not required to obtain InComm devices. Merchant will need to provide their own USB Swipe Magnetic Card Reader and USB Scanner for scanning items.) Your business will not receive a terminal device if Web Application is selected.

Check "Yes" if more than one terminal is needed

YesIf locations require more than one Terminal at their location and the terminal requested is more than what was originally contracted. There will be an additional $150.00 charge per terminal added to the current contract.

How many Terminals will you require?

BUSINESS ADDRESS INFORMATION

Address 1

ex: 123 SW Main Street

Address 2

ex: Suite, Building

City

State

Business Zip Code

Is the Billing Address different from the Company Address?

YesNo

BUSINESS BILLING INFORMATION

Billing Address Line 1

ex: 123 SW Main Street

Billing Address Line 2

ex: Suite, Building

Billing City

Billing State

Billing Zip Code

Billing Phone Number

ex: 111-11-1111

VERIFY PRINCIPAL INFORMATION

Note: All Principal information is required and should include the business owner's personal information only

Principal First Name

Principal Last Name

Principal Email

Principal Phone

ex: 111-111-1111

Business Owner Title

If "Other" Title is selected. Enter other title here

Home Address 1 (Home Address is REQUIRED as part of the background check on the Principal applying.)

ex: 123 SW Main Street

Home Address 2

ex: Suite; Building

City

State

Home Address Zip Code

AS A REMINDER: ALL VX520 TERMINALS WILL NEED TO BE RETURNED TO INCOMM TWO WEEKS AFTER YOUR NEW TERMINAL RECEIVED DATE. USE THE RETURN LABEL INCLUDED IN YOUR NEW TERMINAL BOX AND SHIP YOUR OLD EQUIPMENT TO OUR INCOMM WAREHOUSE BELOW:

INCOMM WAREHOUSE 555 INTERNATIONAL PARK SUITE 100 NEWNAN, GEORGIA 30265