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
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.