Allegiant ATM Intake Form

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Five Star Representative Intake Form

Location/Factory

Name of Location *

Street Address *

Street Address Second Line

City *

State *

Zip *

Contact Name and Title *

Contact Phone Number *

Contact Email Address *

Number of Employees *

Is there a credit Union Associated with the location? *

Yes

If yes, what is the name?

Does location already have an ATM? *

Yes

Verplicht

Select Program *

Standard Program - requires 400+ employees

Free Surcharge Program - requires 300+ employees

Verplicht

Five Star Representative

Name *

Phone Number *

Email Address *

In the event an automated teller machine is placed in this location, a commission, in the form a prepaid gift card, will be emailed to the Five Star Representative to the email address provided.

Verzenden

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Dit formulier is gemaakt in BaumtTech ATM. Misbruik rapporteren

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