| 1) Type of ATM Service Requested: (Please Check All That Apply) |
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| 2) Type of Location: |
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| 3) Number of Daily Visitors: |
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| 4) Number of Daily Foot Traffic in Front of Your Location: |
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| 5) Forms of Non-Cash Payment Accepted: |
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| 6) Do you currently have any ATM Machines? |
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| 7) What type of ATM Machines are you considering? |
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| 8) Describe the Area Around Your Location: |
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| 9) Please provide us with any other info you feel will help us understand your business environment better, such as an ATM machine right next door, a bank ATM down the street, etc. If the ATM is for a special event, please describe the event. |
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