Agent Purchase Form

Date:

Agent Name:

Store Name:

Store Email:

Store Phone:

Shipping Address (if different from store address):

POS Bundle

POS Type:

Quantity:

Blank Database Required:

Credit Card Pinpad:

Quantity:

Stand:

*not applicable for D210

Scanner:

Quantity:

Additional Scanner:

Quantity:

Cash Drawer:

Quantity:

Receipt Printer:

Quantity:

Keyboard/Mouse:

Quantity:

Label Printer:

Quantity:

Back Office Software:

*For additional Back Office Software licenses, there will be additional cost

Scan Data:

Loyalty:

Data Transfer:

*If Yes, please fill the Data Transfer Form

PtechPOS Software:

Note: We are not responsible for any unresponsive merchandise