EchoSat Gateway Site Application

Doc. No.: M030002-C Rev. 0
Page 1 of 2
M030002-C Pacific Pride CustomerEchosat Secure Gateway Application
IMPORTANT: YOU MUST COMPLETE AND FAX THIS FORM to 603-778-7393 at least one
(1) business day before your OPW IP Converter can be installed and activated.
The information on this form will be used to establish a secure connection to card processors via the Echosat
gateway. A contract approval email will be sent from Echosat to the email address listed below. One-time setup
and monthly fees apply.
For your convenience, this form can be filled out electronically.
Customer and Site Information
What company is responsible for bill payment for this site?
Company Name:
Street Address:
State: Select
City:
Phone:
Fax:
Zip:
Federal Tax ID#:
For the company listed above, who will approve the site contract?
Name:
Title:
Email:
Phone:
Who is your OPW hardware distributor?
Company Name:
Contact Name:
Phone:
Site information where the IP Converter is being installed
Site Name:
Unique Site ID#:
Street Address:
City:
State: Select
Emergency Contact for Site Issues:
Phone:
Zip:
IP Convertor Information: (This information is found on the bottom of the device)
Serial No.:
Ethernet Address: 00:80:44:
Doc. No.: M030002-C Rev. 0
Page 2 of 2
Pacific Pride Customer Fee Structure
The information below details the Monthly and One-Time fees associated with establishing a
secure connection to card processors via the Echosat gateway.
Echosat Fees:
Select the term of service for Echosat Account:
Echosat Monthly Fee options (select one of the following):
No Term @ $49.95 per month
12 months @ $39.95 per month
24 months @ $34.95 per month
36 months @ $29.95 per month
Echosat Set-up Fee (one-time only)
$55.00
Comdata Fees (optional)
Comdata is available for all customers. To activate this service additional fees are required.
Yes, I would like to activate Comdata.
Comdata Monthly Fee:
$14.00
Comdata Boarding Fee (one-time only):
$50.00
Total Fees
Echosat Monthly Fee
$ 49.95
Echosat Set-up Fee
$ 55.00
Optional Comdata Monthly / Boarding Fees
$ 0.00
__________________________________________________
TOTAL
$ 104.95