Payment Gateway Certification Request Form

MeS Payment Gateway

Certification Request Form

Company Information
Date
Company Name
Company Address
City, State, Zip
Company Phone
Company Website URL
Your business can be described as a	Merchant Reseller
If you selected reseller, would you like your company information posted to our website?	Yes No
Reseller Product Information	Name to be listed: Version to be listed:
If you selected reseller please indicate your card security compliance	PCI Certified PA-DSS Certified Not Certified
Are you registered as a Service Provider with another processor?	If yes, processor name:
Contact Information
Primary Contact	Name / Title*
	Phone Number(s)*
	Email Address*
Sales Contact	Name / Title
	Phone Number(s)
	Email Address
Technical Contact	Name / Title
	Phone Number(s)
	Email Address
Product Information
Card Types Accepted	Visa MasterCard	American Express Discover JCB
Payment Types Accepted	e-Commerce Mail / Phone Order Recurring Payments 3D Secure/MeS 3D Secure/3rd Party Partial Authorization	Pinned Debit Retail Card Present (swiped) Business to Business Level 2 Business to Business Level 3 International
Record Types Accepted	Sale Refund Store Card Option Verification Only Re-Authorization	Pre-Authorization Settle Pre-Authorization Void Dynamic DBA
Miscellaneous
Miscellaneous Services	American Express Enhanced AVS Retry Request Service Visa/MasterCard Account Updater Service API Reporting Service MeS Managed Recurring Billing Service (RBS) Batch Processing

* Required Fields

mes_certification@merchante-solutions.com