Approved
Name:
Amount:
Card Type:
Card Number:
Authcode:
AVS Result:
CVV Result:
OK
OK
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Mark Hertz Company
365 Route 59, Suite 150 • Airmont, NY 10952
A Division of
Personal Information
Full Name
*
Zip code
*
Email Address
*
Transaction Details
$
Amount
*
Property Address
Invoice / Proposal Number / Violation Number
*
Sales Person
Credit Card Details
Pay with Check
Card Number
*
MMYY
*
CVV
?
Account Holder
*
Routing Number
*
Account Number
*
Choose Account Type:
Checking Account
Savings Account
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
Mark Hertz Company
365 Route 59, Suite 150
Airmont, NY 10952
Tell: 845-368-4340
[response]
ID #[transid]
[created]
[cardholder]
$ [amount]
[cardtype] [ccnum4]
Authorization Number
[authcode]
AVS Response
[avsresult]
CVV response
[cvcresult]
[otherTransaction]
