Business Name
*
Legal Entity Type
LLC
Corporation
Sole Proprietor
Partnership
Non-profit
Other
Years in Business
<1
1-3
4-7
8-15
16+
Primary Contact
*
First Name
Last Name
Title/Role
Email
*
Phone
*
(###)
###
####
Preferred Contact Method
Phone
Email
Text/SMS
Business Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Business Hours
Placement Environment
*
Convenience Store
Bar/Nightlife
Restaurant
Hotel/Lodging
Laundromat
Gas Station
Retail/Strip Center
Smoke/Vape
Dispensary
Event Venue
Other
Access Type
Public Access
Staff/Private
Members Only
Estimated Monthly Traffic
<1000
1,000-3,000
3,001-7000
7,001-15,000
15,000+
Existing ATM On-Site?
*
Weekly Cash Available for Loads
*
$5,000
$10,000
$15,000
$20,000+
Not Sure
Who Will Load the Cash?
*
I will
A staff member
To be determined
Safe On-Site for Cash?
Camera Coverage at ATM Area?
Power Outlet Within 6 ft?
Settlement Bank in Place
*
Some banks restrict ATM settlements—we can advise if you’re unsure.
Settlement Bank Name
Funding Preference
Next-day
2-day
No preference
Reporting Preference
Estimated Monthly Withdrawals
<300
300-600
601-900
901-1,200
1,200+
Preferred Surcharge
Start Timeline
*
ASAP (1-2 weeks)
2-4 weeks
1-3 months
Just researching
Compliance & Consent
*
Notes/Comments
