Welcome, we are glad that you have chosen to be a Distributor of Trantech ATM! We strongly suggest you contact us for any prelimenary questions or concerns regarding your new Distributorship. 1 (877) 629-6400 Company Name and Address * INDICATES A REQUIRED FIELD Company Legal Name DBA Name * Address 1 * Address 2 City * State * Please select a state 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 Code * Corporate phone number * Sales phone number Service phone number Fax number Email * Website Company Information Type of Organization Sole Proprietorship LLP/LLC Partnership Corporation Type of User Please pick one ATM Distributor / Reseller Independent Service Organization Service Technician / Engineer Merchant / Retail Store Owner Leasing Agent Network Processor ATM Manufacturer ATM Solutions Vendor Banking Manager Advertising Agent Financial Consultant News Reporter / Media Government Education Consumer / ATM user Other State of Incorporation Please select a state 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 Date of Incorporation ---- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ---- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ---- 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Federal Tax ID No. Corporate State ID No. Reseller Permit Number Number of Years in Business  yrs Number of Years in ATM Business  yrs Management Information   Please Enter Name President/CEO/Partners Manager of Sales/Marketing Manager of Service Organization Number of Direct Employees Select number 1 - 2 3 - 4 5 - 10 11 - more Business Information Products currently distributing Tranax Triton Tidel Diebold NCR Others ATM unit sales in the past 3 months 6 months 12 months   Sales Forecast for the next 3 months 6 months 12 months   Revenue for the last 12 Months  ATM Sales ATM Processing and Management $ $ * do not include commas Names of Processing Companies Names of Networks registered with Service Organization Information # of units under your company's management Owned Processing   States where your company has ATM machines installed and serviced Service hours Service organizations that your company has contracts with Describe the service program, or programs, that your company offers to ATM owners List manufacturer names your company received certified service training from Miscellaneous Information Please provide any additional information that you would like to give to Trantech ATM.

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