Application Form

Please complete all of the required fields in this online application form. If you require assistance, please feel free to contact us via email - info@paymentexpress.com

Business Information

Company Information

Trading Name:
Legal Name:
Business Description:
Website:
Company Reg #:
Business Type:

Account type

Account Type:
Please select 'Standard' unless you are a web developer that requires Payment Express for testing purposes only.

Address Information

Physical Address

Street:
City:
Country:
State:

Postal Address

Street:
City:
Country:
State:
Same as physical address

Contact Information

Management Contact

First Name:
Last Name:
Phone:
Email Address:
Fax:
Title:

Technical Contact

First Name:
Last Name:
Phone:
Email Address:
Fax:
Title:
Same as management

Accounts Contact

First Name:
Last Name:
Phone:
Email Address:
Fax:
Title:
Same as management

Product selection

Products:
Unsure
Help me please
Ecommerce - DPS hosted
Account2Account
PX Access
PxPay 2.0
Ecommerce - Merchant hosted
PX Fusion
PX Post
Web Service
Integrated EFTPOS
Integrated EFTPOS
Integrated EFTPOS - Wireless
Wireless GPRS Back up
MOTO (online payment portal)
Payline - Merchant portal
Batch Processing
Batch Processor
sFTP Batch Processor
IVR
IVR (Interactive Voice Response)
Unattended Payments
Kiosk
Other
Parking
Vending
Please select the product(s) you require. If you are unsure, please select 'Unsure' and a member of our presales team will be in touch to discuss your requirements.

Partner codes

If you have a partner code, please enter it now:
Partner Code:
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