Approved

Name:

Amount:

Card Type:

Card Number:

Authcode:

AVS Result:

CVV Result:

OK

Bmt

Personal Information

Full Name ^*

Address

Zip code

Phone Number

Email Address ^*

Transaction Details

$

Amount ^*

Description

Repeated Payments

Ongoing 2 Months 3 Months 4 Months 5 Months 6 Months 8 Months 10 Months 12 Months 18 Months 24 Months 36 Months

Credit Card Details

Pay with Check

Card Number ^*

MMYY ^*

CVV

?

Process Payment

Processing By

Merch Pay, Inc. is a registered ISO of Wells Fargo Bank, N.A., Concord, CA.

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Credit & Debit Processing | Electronic Check Services | Gift & Loyalty Programs | Customized POS Solutions

Bmt

167 High Street
Passaic, NJ 07055

Tell: 973-778-9211

[response]

ID #[transid]

[created]

[cardholder]

$ [amount]

[cardtype]   [ccnum4]

Authorization Number

[authcode]

AVS Response

[avsresult]

CVV response

[cvcresult]

[otherTransaction]

Thank you for your payment.