Site Installation Profile

Instructions: Please enter ALL information requested below and email the completedform to or, print out the form, fill in all information (please print) then fax it to 515-986-7898. If multiple bays are being installed at the same site, a separate Site Installation Profile must be completed for eachbay.

Requested Installation Date and Time:
What type of installation is this?
/ New Equipment / Retrofit existing Equipment

**Note: A minimum of 45 days notice is required to schedule an Intelio technician to do an on site installation.

***Two weeks prior to scheduled installation date, Customer shall confirm that ALL required items are complete. After confirmation, customer is responsible for incremental cost associated with re-scheduling installation. Reschedule dates subject to technician availability.

Seller Information

Company Name:
CompanyAddress:
Company City, State & Zip Code:
Company Office Phone:
Contact Name for this Installation:
Contact’s Email Address:
iConnect login instructions for the Sellers User Account will be emailed to the above email address.
Seller Contact’s Mobile Phone Number:
Seller’s Mobile Phone Service Provider:
(e.g. Sprint, T-Mobile, Verizon, AT&T, Cingular, Nextel, Etc. – Required for Receiving Text Message Alerts)

Site & Owner Information

Car Wash Site Business Name:
Car Wash Site Address: *
Car Wash City, State & Zip Code:
Car Wash Site Phone Number:
Preferred Car Wash Site ID: (max. 6 characters)
Owner’s Full Name:
Owner’s Company Name:
Owner’s Office Phone Number:
Owner’s Email Address:
iConnect login instructions for the Site Owner’s User Account will be emailed to the above email address.
Owner’s Mobile Phone Number:
Owner’s Mobile Phone Service Provider:
(e.g. Sprint, T-Mobile, Verizon, AT&T, Cingular, Nextel, Etc. – Required for Receiving Text Message Alerts)
On-Site Manager Name & Phone Number:

IConnect Modules

Which iConnect Modules were Ordered: /
Select all that have been purchased
Broadband Credit Card Processing
Market
Links
Manage
Type of POS System in C-Store:

Coin Box Information

Coin Box Model:
(EnterACT, AMTT CS, AMTT)
If a retrofit installation, which of the following options have been installed or ordered? / Yes / No
Card reader
Receipt Printer

Credit Card Processing Information

Credit Card Setup Status: / Yes / No / Contact Terry Hirsberg for assistance. He represents;
Total Payment Solutions Inc.
217 Country Club Park # 641
Birmingham, Alabama 35213

Office- 205-956-9052
Cell – 205-540-0239
Fax – 205-956-9009
Please inform Terry this is an iConnect location powered by Intelio. *
Has the customer filled out and submitted credit card authorization paperwork?
Has the merchant account or transaction processing account been approved and established?

Car Wash Equipment Information

Wash System Model:
Which of the following options are installed? / Yes / No
Undercarriage
Two-Step Presoak
Wheel Scrub
Rocker Panel Blaster
Bug Buster
Rain Shield
On-board Dry
Standalone Dry
20 Horsepower
30 Horsepower

Configuration/Price Information

Wash Package Information: / Wash Package Name / Price
Wash Package 1
Wash Package 2
Wash Package 3
Wash Package 4
Package Plus Options: / Package Plus Name / Price
Package 1 – Package Plus Service A:
Package 1 – Package Plus Service B:
Package 2 – Package Plus Service A:
Package 2 – Package Plus Service B:
Package 3 – Package Plus Service A:
Package 3 – Package Plus Service B:
Package 4 – Package Plus Service A:
Package 4 – Package Plus Service B:

Networking Information

Broadband Status: / Yes / No
Has Broadband service been ordered for the wash site?
Has the Broadband service been installed and tested for Internet connectivity?
Is the Broadband shared with other computers/devices at the wash site?
Broadband Service Provider:
Broadband Service Provider Support Phone #:
Broadband Account Holder Name:
Broadband Account Type:
(e.g. Cable, DSL, Wireless, Frame Relay)
Broadband Account Username:
Broadband Account Password:
Any Additional BB Account Login Info:
(e.g. URLs, Online Login Information, etc.)
BB Modem Make and Model:
Network Admin Name:
Network Admin Phone Number:

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