*Store Name

*Where did you hear about us?

*Wholesaler Name

*Wholesaler Store Number

*Completed By:

*Store phone number:

*Store street address:

*Store city:

*Store state:

*Store zip code:

Grind Log Reporting Store Level (Up to 3 emails)

*Email #1

Email #2

Email #3

Corporate Reporting For More Than 1 Store (Up to 3 emails)

*Email #1

Email #2

Email #3

*Billing Name

*Billing Email

Technical Contact (Name, Email, Phone)

P.O.S. Vendor (Name, Email, Phone)

*Do you use Vendor Safe?
NoYes

*Does your store use a static IP address?
NoYes

If yes to using a static IP, please provide the following:

IP Address:

Subnet Mask:

Default Gateway:

G.O.T. SYSTEMS NEEDS PORTS 61200, 61250, 61300 AND 61350 OPENED FOR SCANNERS TO COMMUNICATE WITH OUR SERVERS

*Where should we ship your equipment?