Basic "Transparent" Payment Form

(No User facing Gateway)

Description

This is a transparent payment form meant for Merchants that don't want or need direct integration with their internal databases but don't want the user to ever have leave the Merchant's site when paying.

The form will:

Take the input from the form below.
Forward the information to the PCI Compliant Gateway in the background, the User does not see this.
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 to a page on the Merchant's site pre-defined by the Merchant.

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 will be directed to a "Thank you for you submission" type page and would await an E-Mail indicating approval of the transaction.

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

First Name:
Last Name:
Address:
City:
State:
Zip:
EMail :
CardNo:
ExpMonth:
ExpYear:
CVV2:
Select:
Total:
Submit: