Contactless Payment Device Order

Thank you for your interest in the Contactless Payment products represented by DuBois Chemicals Australia. Please complete the form below to order devices for your carwash facility. Once submitted to us your order will be reviewed and we will email a confirmation to you.

Customer Details

Full Legal Organisation Name(required)

ACN(required)

ABN(required)

Contact Name(required)

Title(required)

Site Address(required)

Trading Name(required)

Telephone No.(required)

Email(required)

Prowash Account?

Yes    No

Account Number(optional)

Order Details ^{# * ^}

Self Serve Bay(optional)

Auto Entry*(optional)

Vacuum(optional)

Dog Wash(optional)

^# Sale Subject to Prowash's Terms & Conditions
* Suitable for Anztec & Mr Magic (May require Merlin 2 upgrade)

Other Details(optional)

Security Code(required)

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