Scanner deployment order Form
FRM-0010 Version 6.6
General InformationDirect Sale / Date Submitted: / Submitted By: / Submitter’s phone: () -
Customer Shipping Information
Company: / Contact Name:
Address: / Contact Phone: / () -
City, ST Zip: / Contact Email
Shipping options
Orders will be shipped viaGround shipping unless otherwise requested.
Order
3 YEAR ADVANCED eXCHANGE PLAN
Scanners
Quantity / Price / Make/Model
$
*Unit Cost does not include shipping cost or tax, which is charged separately.
PAYMENT OPTIONS
ACH DEBIT AUTHORIZATION* *Expect 4 days for payment to process
I hereby authorize Bankserv to initiate debit entries to my account indicated below, and the financial institution named below to debit the same to such account. By agreeing to a debit authorization, I authorize Bankserv to initiate a debit entry (withdrawal, transfer, etc.) at the financial institution named below. Items returned for non-sufficient and/or uncollected funds will be represented for payment. If I do not have enough money in my account to cover the transfer or if my financial institution for any other reason refuses to honor a transfer, I will separately pay for the charges I owe under my agreement with Bankserv.
I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.
Financial Institution:
Branch:
City: State: Zip:
Routing/Transit Number:
Account/Bank Number:
Signed this _____ day of _____, 200_____.
By: Name: Title:
CREDIT CARD DETAILS** **Expect 1 day for payment to process
I hereby authorize Bankserv to charge the credit card indicated below for the total amount of the order including any applicable taxes. If my credit card is denied, I will separately pay for the charges I owe under my agreement with Bankserv. (Enter your credit card details exactly as shown on your credit card and billing statement.)
Name: Phone:
Company:
Billing Address:
Credit Card Type (Visa/MC/Discover): Credit Card Expiration Date:
Credit Card Number:
Signature of cardholder:
Fax Your Completed Scanner Order to 866-284-1151. The sender of this electronic order form warranties that they are authorized to order the equipment and/or services as indicated on the order form. The sender agrees that Bankserv can use the sender’s email information associated with the order form as proof of order by the sender. Contact scanner support at (866)562-5640 with any questions or concerns.
FRM-0010 Version 6.6