Site Survey Form

    Survey Date:

    Client Information

    Company Name:

    Site Information

    Estimate Installation Date:

    Your Current POS


    [group Verifone-Ruby-CI-commander-version-g]

    [/group]

    [group Verifone-Ruby-Topaz-Commander-g]

    [/group]


    [group other-POS-g]

    [/group]

    *To find out the version of the commander:
    1 - Go to CSR Menu (bottom right corner)
    2 - Select option 5
    3 - Login with the manager ID and Password
    4 - Click "Help" & then "About", the version will be shown under Configuration

    Forecourt Type


    [group Forecourt-Other-Type-g]

    [/group]

    Network

    [group Other-Network-g]

    [/group]

    Debit Encryption Key:


    [group Wayne-Dispenser-Model-g]

    [/group]


    [group Gilbarco-Dispenser-Model-g]

    [/group]


    [group Tokheim-Dispenser-Model-g]

    [/group]


    [group Bennett-Dispenser-Model-g]

    [/group]

    How Many Dispensers (MPD):

    How Many Pumps/Fueling Positions:

    No Of Tanks:

    Grades:

    Tank Size:

    Dispenser Pictures

    Please provide dispenser pictures: one of the Outside of dispenser door (include card reader) and
    one of the Inside of dispenser door

    Full Pump Picture:
    (Taken From Aleast 10 Feet Away )

    Inside Of Dispenser Door:

    Outside Of Dispenser Door:

    Types Of POS(Ruby etc):

    Fuel Controller Box:

    Fuel Setup Area(D-Box,G-Box etc):

    Internet Setup(Cyberia, MAACO etc):
    (Optional)

    Current Credit Card Processing Statement: