Approved
Name:
Amount:
Card Type:
Card Number:
Authcode:
AVS Result:
CVV Result:
OK
OK
Cancel
Fulton Center For Rehabilitation
847 County Hwy 122 • Gloversville, NY 12078-6413
Personal Information
Full Name
*
Address
Zip code
Phone Number
Email Address
*
Transaction Details
$
Amount
*
+ Convenience fee: 3%
on
credit card
transactions
Final Amount
Residents Name
*
Residents Phone
*
Payment for Month
Pay in Installments
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
12 Months
Recurring Payments
Ongoing
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
12 Months
Credit Card Details
Pay with Check
Card Number
*
MMYY
*
CVV
?
By clicking this form, you give Fulton Center For Rehabilitation permission to charge your account as indicated below. This does not provide authorization for any additional unrelated charges to your account.
Account Holder
*
Routing Number
*
Account Number
*
Choose Account Type:
Checking Account
Savings Account
By clicking this form, you give Fulton Center For Rehabilitation permission to charge your account as indicated below. This does not provide authorization for any additional unrelated charges to your account.
Process Payment
Processing By
Merch Pay, Inc. is a registered ISO of Wells Fargo Bank, N.A., Concord, CA.
merchant login
merchant login
merchant login
merchant login
Credit & Debit Processing | Electronic Check Services | Gift & Loyalty Programs | Customized POS Solutions
Fulton Center For Rehabilitation
847 County Hwy 122
Gloversville, NY 12078-6413
Tell: 518-773-3400
[response]
ID #[transid]
[created]
[cardholder]
$ [amount]
[cardtype] [ccnum4]
Authorization Number
[authcode]
AVS Response
[avsresult]
CVV response
[cvcresult]
[otherTransaction]
