• Repleni-Trac™

    Order Verification Form
  • Is this request to add locations to the existing RTV contract?*
  • Responsible Party Information

    • View Vault Images 
    • Large vault - 24" H x 14" D x 14" W (109 lbs)

    • Image field 212
    • Small vault - 15" H x 14" D x 14" W (72 lbs)

    • Image field 214
    •  
    • Location 1 Details

    • Requested Install Date*
       - -
    • Current AllyDVM User?*
    • Kiosks

    • Vaults

      Indicate quantity of each vault needed.
    • You must select at least 1 vault.

    • Site Setup & Installation - $1,499.00

      Monthly Cost - {Loc1TotalMonthly}

    • Location 2 Details

    • Requested Install Date*
       - -
    • Current AllyDVM User?*
    • Kiosks

    • Vaults

      Indicate quantity of each vault needed.
    • You must select at least 1 vault.

    • Site Setup & Installation - $1,499.00

      Monthly Cost - {Loc2TotalMonthly}

    • Location 3 Details

    • Requested Install Date*
       - -
    • Current AllyDVM User?*
    • Kiosks

    • Vaults

      Indicate quantity of each vault needed.
    • You must select at least 1 vault.

    • Site Setup & Installation - $1,499.00

      Monthly Cost - {Loc3TotalMonthly}

    • Location 4 Details

    • Requested Install Date*
       - -
    • Current AllyDVM User?*
    • Kiosks

    • Vaults

      Indicate quantity of each vault needed.
    • You must select at least 1 vault.

    • Site Setup & Installation - $1,499.00

      Monthly Cost - {Loc4TotalMonthly}

    • Location 5 Details

    • Requested Install Date*
       - -
    • Current AllyDVM User?*
    • Kiosks

    • Vaults

      Indicate quantity of each vault needed.
    • You must select at least 1 vault.

    • Site Setup & Installation - $1,499.00

      Monthly Cost - {Loc5TotalMonthly}

    • Leaving TM Approval as XXX will keep this JotForm in draft state.

      Providing TM Approval initials will move this to contracting with the customer.

    • Implementation Kickoff Use Only 
    • Contract Effective Date*
       - -
    • Location 1 Details

      Contact Name: {Loc1ContactName}

      Contact Phone Number: {Loc1ContactPhone}

      Contact Email Address: {Loc1ContactEmail}

      Contact Address: {Loc1address}

      Current AllyDVM User? {Loc1AllydvmUser}

       

    • Secondary Contact Information

    • Network Connection*
    • Current System*
    • Logs*
    • PDMP*
    • Have you used PDMP in the past?*
    • Customer Time consuming*
    • Who maintains log books*
    • Should be Empty: