Order Number Your First Name * Your Last Name * Your Email Address * Name of Organization * Event Information Event Date * Credit card volume at last year's event * Please let us know your estimated credit card volume. If you are not sure, an estimate is OK. Expected Number of Guests * Please let us know how many guests you are expecting. Spire will send one complete unit (Chromebook, mouse and card reader) for every 100 expected guests. Tax ID (EIN #) Address Street Address City State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Organization Phone Organization Email Is this email address where you would like notifications such as the Sync 3 report sent to? * Yes No If no please provide us with the email address where you would like email notifications sent to Use different shipping address? * Yes No Where shall we ship the equipment to your event? Shipping Address Street Address City State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip A federal mandate known a the Anti Money Laundering Act, requires that an applicant who wishes to utilize financial services from a third party such as Priority Payment Solutions must provide the following information.Signer Information The person in this section must be the same person that signs the Merchant Processing Agreement (MPA). First Name Last Name Please provide us with your date of birth (Uncle Sam's requirement) * Home Address City State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Best Contact Phone Number Schedule D ACH Authorization I (we) hereby authorize Spire Payment Solutions hereinafter called COMPANY, to initiate debit entries to my (our) D Checking Account/ D Savings Account (select one) indicated below at the depository financial institution named below, hereinafter called DEPOSITORY, and to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law. What is the name of your bank Authorizing Officers Name Title Does this bank account have an ACH block attached to it? If YES, We have an ACH block in place NO, We do not have a block on our bank account This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it. You will be notified by email to send us a voided check. We cannot open a Merchant Processing Account with this. Captcha *
