WPS New Site Form

Please complete and submit this form with as much detail as you can provide regarding contact info and the types of payment methods and hardware quantities that are planned for the new installation.

Client Business Name

Contact Email

Contact Name

First Name

Last Name

Contact Phone

(###)

###

####

Installation Date

Scheduled/estimated date of payment device installation

YYYY

Payment Device Types

Device types to be installed

Unattended (Globalcom BV1000R)

Attended (Ingenico Lane 3000, other handheld device)

Pay-by-phone (WPS Pay, QR code)

WPS Channel Partner Business Name

Channel Partner Contact Name

Channel Partner Email

Channel Partner Phone

(###)

###

####

WPS New Site Form

Home Office

Contact