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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