Intake Form All

KioCentral Intake Form
Market*

LaundryAmusementsVendingCoffeeOther
KioSoft Distributor/ Partner Information
Distributor (Sales) Company Name*
Representative Name*

Your First NameYour Last Name
Representative Email*
example@example.com
Customer/ User Information
Customer Name*

First NameLast Name
Customer Email*
example@example.com
Customer Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Merchant Information
Company or Doing Business As Name*
Legal Business Name*
Employer Identification Number (EIN) / Business Number*
A nine-digit number that IRS assigns in the following format: XX-XXXXXXX.
Location Name (If different from company name)*
Type "Same" if same as company name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Merchant Account Type*

Merchant Account (This is a direct processing account)KioSoft Express (KioSoft owns the processing relationship)Moneris (Canadian customers only)
Equipment Information

KioSoft Equipment purchased
Type of System Purchased*

Ultra LX or VX (pay-at-the-machine)Ultra VQ-M (pay-at-the-machine with modem)Vending Machine with Ultra ReaderAVU Touch series kiosksVC Series kiosks (credit and/or cash)Soap StationKioSoft POSMobile only
Number of Ultras*
Number of Ultra VQ-M*
Number of AVU kiosk*
Number of VC kiosk*
Number of Soap Stations*
Number of KioSoft POS*
Number of Mobile readers*
Number of Vending Machines with Ultra Reader*
Will you be using a KioSoft Modem*

YesNo
Modem Communication Type*

Cellular Data Standard CapacityCellular Data High CapacityEthernet Standard CapacityEthernet High Capacity
Number of Modems
Will the VC Touch Kiosk be in Credits Mode or Value Mode?*

CreditsValue
Please list the amounts for card refills at the Touch Kiosk and if any bonus should be applied based on the amount paid.*
Notes
If you have any additional comments, please list them here.
Laundry Machine Model Numbers*
Are you using COIN?*

YesNo
KioCentral - Customer Server Name*
Type the desired name of the Customer's server
Click here if VMS (Vending Management System)
Attachments (optional)

It is recommended that you attach any PO or OC for this particular sale.
Cancelof
Should be Empty:

KioCentral Intake Form

KioSoft Distributor/ Partner Information

Customer/ User Information

Merchant Information

Equipment Information