Payment Gateway Order Form

Step One - Merchant Information


DBA (Doing Business As) Name
Legal Name of Business
Business Phone
Business Fax
Business Address
Business City
Business State
Business Zip Code
Main Phone Number
Merchant Website URL
Authorized Company Contact
First Name
Last Name
Title or Relationship
Contact E-mail

Step Two - Owner Information


Principal's Information
First Name
Last Name
Date of Birth
Home Phone
Ownership %
Owner's Home Address
City
State
Zip Code

Step Three - Business Information


Merchant ID:
Terminal ID:

Step Four - Payment Information


Cardholder Name:
Card Number:
Expiration Month:
Expiration Year:

Total: $29.95

MCPS Agent ID:
I agree to the terms of service and policies established by MCPS.