Owner Information



POS Payment Information

Please fill out the form completely—choosing only 1 payment option

and providing all requested information.

FAX completed form to Richard Vale at (480)-362-4796.

|Store Information |Store # |Brand | Traditional |Today’s Date |

| |      |      |Non-traditional |      |

| |Franchisee Name |E-mail |

| |      |      |

| |Store Address |City |State |Zip |

| |      |      |      |      |

| |Phone |Fax |

| |      |      |

|Purchase Information |Item / Service Purchased |Price |      |

| |      | | |

| | |Tax |      |

| | |Shipping |      |

| | |TOTAL owed |      |

|Payment Option #1 |ACH Amount |Kahala Store Owner Signature |

|ACH | | |

| |$       | |

| |ACH payments greater than $500 may result require an additional 2 days for authorization. |

|Payment Option #2 |Neptune Equipment Wiring Instructions |Name of Bank JP Morgan Chase Bank, N.A. |

|Wire | |Address of Bank Phoenix, AZ 85073 |

| | |ABA/Routing Number 122100024 |

| | |Name on Account Neptune Equipment Services, LLC |

| | |Account Number 754085025 |

| |Store # |Brand |Kahala Store Owner Name |

| |      |      |      |

| |Wire Amount |Kahala Store Owner Signature |

| | | |

| |$       | |

| |All of the above information must be provided; otherwise delays in orders or fund applied to wrong accounts may occur. |

|Payment Option #3 |Name on Card |Billing Address (Street Address, City, ST Zip) |

|Credit |      |      |

|Card | | |

|AMEX | | |

|Visa | | |

|MasterCard | | |

|Discover | | |

| |Credit Card # |3-Digit Code on Back |(AMEX) 4-Digit Code on Front|Exp Date |

| |      |      |      |      |

| |Amount to be Charged to Card |Kahala Store Owner Signature |

| | | |

| |$       | |

| |All of the above information must be provided; otherwise delays in orders may occur. |

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