CARD READER DEVICE ORDER FORM

DBA Name of Office / MID device(s) will be used at:*

PAX A920 PRO

✔ Wireless Device
✔ Connects Via Wifi or Mobile Network
✔ Touchscreen
✔ Tap-To-Pay and Chip-Insert Features

PRICE PER UNIT

$600

PLUS SHIPPING

Enter the Quantity of Devices for Purchase

Electronic Signature *

Signed Date*

Enter the Shipping Address Below

Street Address

City

State

Zip Code

PLEASE NOTE: PAX Devices can only be connected to a single MID/merchant account. Practices who may have two or more MIDs in the same physical office (multi-specialty/EINs within same office), would need a separate PAX device to take card-present payments through each MID. Ask your LQpay sales executive if any questions.

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