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Equipment Leasing
Installation Fees:
$100.00
Quantity:
Item Subtotal:
$0.00
Ankle Monitor (per day):
$14.00
Quantity:
Item Subtotal:
$0.00
SoberTrack Monitor (per day):
$14.00
Quantity:
Item Subtotal:
$0.00
$4 per Day Monitor Fee:
$4.00
Quantity:
Item Subtotal:
$0.00
Ankle Monitor Charger:
$75.00
Quantity:
Item Subtotal:
$0.00
SoberTrack Charger:
$25.00
Quantity:
Item Subtotal:
$0.00
Ankle Monitor Car Charger:
$75.00
Quantity:
Item Subtotal:
$0.00
Equipment Replacement Costs
Charger:
$75.00
Select:
Item Subtotal:
$0.00
Ankle Monitor:
$250.00
Select:
Item Subtotal:
$0.00
SoberTrack Unit:
$500.00
Select:
Item Subtotal:
$0.00
SoberTrack Charger:
$25.00
Select:
Item Subtotal:
$0.00
Ankle Car Charger:
$75.00
Select:
Item Subtotal:
$0.00
UA Test Box:
$30.00
Quantity:
Item Subtotal:
$0.00
Total:
$0.00
Physical Address Info. (No PO Box)
First Name:
Last Name:
Address:
Address:
City:
State/Province:
ZIP/Postal Code:
Phone:
Email:
Payment Information:
Processing Fee Rates:
Cards:
2.5% ($1.50 min)
(1.5% surcharge for foreign cards)
Method of Payment:
Credit/Debit Card
Update Name from Above
Name on Account:
Routing Number:
Account Number:
Institution:
Name on Card:
Account Number:
Expiration Date:
Billing Street Address:
Billing ZIP/Postal Code:
Change Payment Method
Please be aware that credit card payments will reflect on your statement as
County UT 8007640844 ClintonUT
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CORE Payments Version 4.1.17016; (API: 2.22)
