Order Form
|ORDER REQUEST TYPE (Required) |
| Purchase & Set Up [Complete All Sections] |Date Needed: |Requested by: |
| File Build Only [Complete Billing & Terminal Set Up Sections] |File Build Number [If available]: |Serial Number: |
|SHIPPING INFORMATION (Required) |
|Company Name: | |Contact: | |
|Address: | |City: | |State: | |Zip: | |
|Telephone: | |Email: | |
|Shipping Method: | Ground (Default) 2 Day Next Day Saturday Other (Note: No PO Boxes) |
|Bill your own account for shipping charges: |Shipping Account #: | |Carrier: | |Special Instructions: |
|EQUIPMENT - POS TERMINALS |Quantity |Price |Total Price |
|NX2200e | Kit (battery, power supply & paper roll) |Communication: GSM WiFi Only | | |$ 0.00 |
|NX1200 | Kit (power supply & paper roll) |Communication: Ethernet | Dial | | |$ 0.00 |
|G3 | Kit (battery, power supply & paper roll) |Communication: WiFi | GSM | | |$ 0.00 |
|G3N | Kit (battery & power supply) | | | |$ 0.00 |
|G3P | Kit (power supply) | USB | Serial | RJ45 | | |$ 0.00 |
|N5 | Kit (battery, power supply, charge only station|Black: WiFi LTE AT&T LTE VZW | | |$ 0.00 |
| |& paper roll) |White: WiFi | | | |
|N6 | Kit (battery, power supply, paper roll & SIM card) | | | |$ 0.00 |
|ACCESSORIES |Quantity |Price |Total Price |
|Li-Ion Battery | NX2200/e/G3 | G3N | N5 | N6 | | |$ 0.00 |
|Power Supply | NX2200/e/NX1200/G3 | G3P | G3N/N5 | N6 | | |$ 0.00 |
|WiFi Stick | Dual Band (2.4/5 GHz) | | | |$ 0.00 |
|G101 PIN Pad | NX1200 | | | |$ 0.00 |
|Docking Station | G3 Charge Only | N5 Charge Only | N5 Hotspot | | |$ 0.00 |
|N5 Accessories | N5 Screen Protector | N5 Silicone Sleeve | N5 Holster | | |$ 0.00 |
|N6 Accessories | N6 Docking Station Printer | N6 Scanner Pro | | | |$ 0.00 |
|Paper | NX2200/e/G3/N5 | NX1200 | | |$ 0.00 |
|SIM card | NX2200e/G3 | N5/N6 LTE AT&T | N5 LTE Verizon | | |$ 0.00 |
|File Build | | |$ 0.00 |
| | | |$ 0.00 |
Billing
| |
|BILL TO INFORMATION (Required) |
|Company: | |Contact Name: | |
|Billing Address: | |Purchase Order #: |
|Billing City: | |Billing State: | |Billing Zip: | |
|Phone: | |Email Address: | |
| CREDIT CARD OPTION |
|Card Type: | Visa MasterCard AMEX Discover |
|Card Number: | ─ ─ ─ |Exp. Date: | / |CVV Code: | |
|Cardholder Name: (as it appears on the card) | |
| INVOICE OPTION (Subject to credit approval. Contact Nexgo for an application and approval of credit terms.) |
|ACKNOWLEDGEMENT. |
|Credit Card Option: My signature below authorizes Nexgo, Inc. to use the credit card listed above for the purchase of goods and/or services as indicated on the |
|sales order submitted. I certify that I am the legal cardholder for this credit card, and that I am authorized to enter into this billing agreement with Nexgo. |
|Invoice Option: My signature below confirms an agreement bound by the terms and conditions of the sale and in lieu of a purchase order. |
|Please fax the signed acknowledgement to 949.266.5658 (Attention: Orders). Orders will not be processed without a signature. For any questions, please contact your|
|Nexgo Sales Manager. |
|Signature: |X |Print Name: | |Date: | |
Terminal Set Up
|TERMINAL SET UP INFORMATION (Required - One setup form required per terminal) |
|Terminal Type: | NX2200 NX2200e NX1200 G3 G3N G3P N5 N6 |Terminal Serial #: |
|RECEIPT HEADER INFORMATION (Required) |RECEIPT FOOTER INFORMATION (Required) |
|1 | |1 |I agree to pay above total |
|2 | |2 |amount according to card |
|3 | |3 |Issuer agreement. (Merchant |
|4 | |4 |Agreement if credit voucher) |
|5 | |5 | |
|Receipt header allows for 5 lines with 27 characters per line. |
|CONFIGURATION INFORMATION (Required) |
|Processor: | FD Nashville FD Omaha TSYS EVO Chase Paymentech (CPS) Global Payments Heartland |
|Gateway: | USA ePay |
|Industry Type: | Retail Retail with tip Restaurant |
|Accept: | Credit Gift Debit EBT |
|Merchant # (MID): | |Terminal # (TID)/Device ID: | |
|CONFIGURATION INFORMATION Continued (Required) |
|FIRST DATA |DATAWIRE ID: | | Auto Discovery |
|(Required for IP only) |(Case Sensitive) | | |
|CPS (Case Sensitive) |NetConnect | |
| |Username: | |
| |Log In ID: | |
|SOFTWARE (N5 only) |
| SoftPoint | ExaPay | Other: |
|COMMUNICATION (*Default Value) |
|Ethernet: Yes* No Dial: Yes No Wireless: Yes No WiFi: Yes No |
|TCP IP / WIFI INFORMATION |
|DHCP Enabled: | Yes No |Static IP: | |Mask: | |
|Gateway: | |DNS1: | |DNS2: | |
|WiFi |SSID (case | |Key: | |
| |sensitive): | | | |
|DIAL-UP INFORMATION |
|Dialing Prefix Code: | Yes No |List Prefix Code: | |
|STANDARD TERMINAL OPTIONS (*Default Value) |
|Prompt for Customer Copy: | Yes* No |Ask Tip: | Yes No |
|Receipt Quantity: | 1 2* 3 |Suggested Tip Rate: | Yes No Tip Rate %: |
| | |(Default 10%, 15%, 20%) | |
|Store & Forward Enabled: | Yes* No |Ask Server: | Yes No |
|Cash-back: | Yes No* |EMV Acceptance: | Yes No |Online PIN: Yes No |
|NOTES |
| |
PLEASE RETURN ALL REQUIRED FORMS TO NEXGO VIA FAX OR EMAIL
Fax: 949.266.5658 | Email: orders@nexgo.us | Toll Free: 866.392.8326 option 4
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