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ATM Advertising Interest Application
Please fill out this application to help us collect the key information needed to consider your ATMs for advertising opportunities. The accuracy of this form dictates your position in the queue to be onboarded.
All information and data submitted through this form will be stored securely and handled in accordance with our
data sharing
policies.
Contact Information
Name
(Required)
First
Last
Email
(Required)
Enter Email
Confirm Email
Phone
(Required)
Preferred Method of Communication
(Required)
Phone Call
Text
Email
Referral Code (if applicable)
Please enter the FourCorners Customer Code of your referrer.
Business Information
Business Name
(Required)
Business Address
(Required)
Street Address
Address Line 2
City
State / Province
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
ATM Ownership & Processing
Tell us about your ATM fleet and how it's managed.
How many ATMs do you currently own?
(Required)
You must own the contract with the location.
Are you a market partner with PAI?
(Required)
Yes
No
PAI Customer Code
(Required)
This is for referral tracking purposes.
Do you have terminals outside of PAI?
(Required)
Yes
No
How many terminals do you have outside of PAI?
(Required)
What state(s) do you operate ATMs in? (Select all that apply)
(Required)
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
What state are the majority of your ATMs located in?
(Required)
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
What types of locations are your ATMs placed in? (Please be accurate and select all that apply)
(Required)
Accommodation
Airport / Train / Bus
Amusement and Recreation
Automotive
Banking / Financial / Credit Union
Beer, Wine, and Liquor Stores
Cannabis
Casino
Dry Cleaning and Laundry Services
Food and Beverage
Gas Station / C-Store
General Merchandise Store
Golf Course / Country Club
Grocery
Legal / Admin / Government
Malls / Department Stores / Retail Clothing
Medical / Hospital
Military, Civic, and Social Organizations
Mobile ATM
Pawn Shop
Personal Care Services
Pharmacy
Professional Services
Restaurant / Bar
Schools, Colleges, and Professional Schools
Smoke Shop
Specialty Retail Store
Sports Stadium
ATM Servicing
How do you handle service and maintenance?
Who services your ATMs?
(Required)
Internal - Me or my team
External - We outsource
This field is hidden when viewing the form
Would you like to be considered for the CBM service provider network?
(Required)
Yes
No
