Basic Payment Form w/ Forward to Gateway

Description

This is a basic payment form meant for Merchants that don't want or need direct integration with their internal databases and/or would rather all the transaction information be handled by the PCI compliant Gateway.

The form will:

Take the input from the form below.
Forward the user to the PCI Compliant Gateway.
The Gateway requests the Credit Card information.
The Gateway will approve or decline the transaction.
The Gateway will then EMail the results to both parties (User and Merchant).
The User will then be Forwarded back to a page on the Merchant's site pre-defined by the Merchant. A separate page can be set depending on if the transaction is approved or declined.

Other fields can be added like Account or Invoice numbers or any specific data the Merchant may need from the user.

Instructions

A user would Enter the requested information below. Once they hit submit, they are taken to a form on a PCI compliant server that can be branded with the Merchant's logo. The information entered here will be pre-populated in the following form, and they will be asked for their credit card information.

Results

Both the User (if they enter a valid e-mail address) and the Merchant will get a confirmation email that will include the order data. The Merchant would then manually enter this payment data into their database.

Please enter your Billing information below

Account #:
First Name:
Last Name:
Address:
City:
State:
Zip:
EMail:
Phone:
Amount:

If you enter an amount with the last digit being an even number (0,2,4,6,8) i.e. 20.00 the transaction will be approved. If you enter an amount ending in an odd number (1,3,5,7,9) i.e. 20.01 the transaction will be declined. This is so you can see either result.