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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