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Survey

Customer
Date

MM
/
DD
/
YYYY
P.O. #
Ship to Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Contact Information (name, phone # and email)
Reader Controllers
 01-0212 MSLR1 
 03-0213 ATM3 
 03-0231 ATMA (NYC) 
 03-0230 ATMA S/W 
 09-0003 56 MODEM For ATMA  
Enter Quantity
Insert Mag Stripe Readers
 62-1001 IR1051F 
 62-1002 IR1051FL 
 63-0042 IR1051FL3  
 62-0042 IR1051FLN2  
 63-0043 IR1051FLN3 
 63-0066 IR1051FLNS 
 62-1006 IR1051FLD 
 62-1004 IR1051FLG  
 62-1009 IR1051SL 
 62-5002 IR1051PL 
Enter Quantity
Swipe Mag Stripe Readers
 62-2011 SR1053SLM 
 63-0018 SR1054FL 
 62-2003 SR1055SL 
 62-5015 SR1058SLE 
 63-0022 SR1058PKL 
 62-5011 SR1063FL 
 62-5009 SE1063FLN 
 62-5003 SR1063SL 
 62-5025 SR1058SLEH 
 62-5012 SR1063SLH 
Proximity Cards
 Prox Card II: (72-0125) 
 ISO Prox II: (72-0003) 
 Key Fob: (72-0133) 
Other (please specify)
Enter Quantity
Encoding Information: Number of bits
 Standard 26 Bit 
 36 Bit 
Facility Code
Card Start Number
Card End Number
C.C.
 M/C 
 VISA 
 AMEX 
C.C. #
Exp Date
POC Code
Name on Card

First

Last
Billing Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Digital Signature
Image Verification
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