SimpleChurch - Giving Kiosk Purchase Form

TYPE OF KIOSK AND QUANTITY
Kiosk Card Reader:	1 Card Reader  (Add $80.00)2 Card Readers  (Add $160.00)3 Card Readers  (Add $240.00)4 Card Readers  (Add $320.00)5 Card Readers  (Add $400.00)
CONTACT INFORMATION
Your Email Address	*
Contact Name	*
Contact Phone Number	*
ACCOUNT INFORMATION
Organization URL/Website	*
SHIPPING WILL BE BILLED SEPARATE FROM THIS TRANSACTION There is a monthly maintenance fee of $19/month per kiosk.
SHIPPING INFORMATION
Shipping Address Line 1	*
Shipping Address Line 2
Shipping City	*
Shipping State	*
Shipping Zip	*
Additional Comments
Total	$