Payecom Order

Thank you for choosing Payecom as your online secure credit card payment gateway service provider.

Please complete the following online application form. You will be taken to our secure Payecom payment page to make payment. All applications are pending approval. No charge will be made against your credit card until your application has been approved.
About You

Your Name:
Your Email:
Your Position:

About Your Business To Use Payecom

Website URL:
Business Name:
ABN (if applicable):
Payment Alert Email:	(Alert emails will be sent here)
Business Phone:
Charging Currency:
Bus. Address Line 1:
Address Line 2:
Town / Suburb:
Post Code / Zip:
State / Province:
Country:

Planned Usage of Payecom

Please provide a brief on what purpose you intend to use your Payecom Gateway

About Your Merchant Account At Your Bank

Do You Have One?	Yes        No
Merchant Account Name:
Bank Name:

Select Payecom Gateway   The Two Gateways Explained

PAYECOM UNIVERSAL Single Licence [$253.00 AU$] Multiple Licence [$341.00 AU$]	or	PAYECOM ST Single Licence [$253.00 AU$] Multiple Licence [$341.00 AU$]
		NOTE: 1. Payecom ST requires the decryption program - available at $187.00 AU$. If choosing the ST service, Payecom Accounts will be in contact with you to arrange delivery of the decrypt program 2. The decryption program is subject to export restrictions and may not be available in your country.

Agreement Requirements:

Does your Merchant Account at your bank allow you to manually charge credit card payments into it that come to you via fax machine, phone, normal mail and Payecom?	YES
Do you understand Payecom's Requirements?	YES See Merchant Requirements
Do you understand and agree to be bound by the Payecom Terms Of Service?	YES See Terms Of Service Agreement
Do you understand and agree to be bound by the Payecom Merchant Refund Policy?	YES See Merchant Refund Policy