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 RequiredWiFi (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 TitlePlease select... President Vice President Treasurer Chief Financial Officer Other 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