payments.jacksonlewis.com
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URL:
https://payments.jacksonlewis.com/
Submission: On August 05 via manual — Scanned from DE
Submission: On August 05 via manual — Scanned from DE
Form analysis 2 forms found in the DOM
POST /Search
<form class="form-inline" method="post" role="form" action="/Search">
<label class="sr-only" for="InvoiceNumber">Invoice Number</label>
<input class="form-control form-control-sm mb-2 mr-sm-2" type="text" placeholder="Invoice Number" id="InvoiceNumber" name="InvoiceNumber" aria-label="Invoice Number">
<label class="sr-only" for="Email">Email</label>
<input class="form-control form-control-sm mb-2 mr-sm-2" type="email" placeholder="Email" id="Email" name="Email" aria-label="Email">
<button type="submit" class="btn btn-outline-jlpurple btn-sm mb-2">
<i class="fas fa-search"></i>
<span class="d-lg-none">Search</span>
</button>
<input name="__RequestVerificationToken" type="hidden" value="CfDJ8Gth1aFK6p5OqZK6VHmx7wKGWUu3Q7URq9AQEQYuC0EguugfgZqqbxyKuJIBwaXdKo6gNYc4XWl315a-Swf3ppCfFtCFB61A9tIjxxcopGgVEtA9_ejbXgSsoOrg9U1LDg8YqjMLWJbo_ASD-4KWSnY">
</form>POST /
<form id="payment_form" method="post" class="form-horizontal mt-5 small" role="form" action="/" novalidate="novalidate">
<fieldset class="border-bottom pb-3">
<legend class="font-weight-bold">Client Information</legend>
<div class="form-row">
<div class="form-group col-md-6">
<label class="col-form-label col-form-label-sm" for="MerchantDefinedData1">Client Name<sup class="text-danger">*</sup></label>
<div class="input-group input-group-sm">
<input class="form-control form-control-sm" type="text" data-val="true" data-val-required="The Client Name field is required." id="MerchantDefinedData1" name="MerchantDefinedData1" value="">
<div class="input-group-append">
<div class="input-group-text input-group-sm-text bg-transparent border-0"> (per invoice)</div>
</div>
</div>
<span class="text-danger small field-validation-valid" data-valmsg-for="MerchantDefinedData1" data-valmsg-replace="true"></span>
</div>
<div class="form-group col-md-6">
<label class="col-form-label col-form-label-sm" for="MerchantDefinedData2">Client Number<sup class="text-danger">*</sup></label>
<input class="form-control form-control-sm" type="text" data-val="true" data-val-required="The Client Number field is required." id="MerchantDefinedData2" name="MerchantDefinedData2" value="">
<span class="text-danger small field-validation-valid" data-valmsg-for="MerchantDefinedData2" data-valmsg-replace="true"></span>
</div>
</div>
<div class="form-row">
<div class="form-group col-md-6">
<label class="col-form-label col-form-label-sm" for="orderInformation_billTo_phoneNumber">Phone<sup class="text-danger">*</sup></label>
<div class="input-group input-group-sm">
<div class=" input-group-prepend">
<span class="input-group-text"><i class="fas fa-phone"></i></span>
</div>
<input class="form-control form-control-sm phone" placeholder="xxx-xxx-xxxx" type="tel" data-val="true" data-val-phone="The Phone field is not a valid phone number." data-val-regex="Phone must be xxx-xxx-xxxx"
data-val-regex-pattern="^[0-9]{3}-[0-9]{3}-[0-9]{4}$" data-val-required="The Phone field is required." id="orderInformation_billTo_phoneNumber" name="orderInformation.billTo.phoneNumber" value="" maxlength="12">
</div>
<span class="text-danger small field-validation-valid" data-valmsg-for="orderInformation.billTo.phoneNumber" data-valmsg-replace="true"></span>
</div>
<div class="form-group col-md-6">
<label class="col-form-label col-form-label-sm" for="orderInformation_billTo_email">Email<sup class="text-danger">*</sup></label>
<div class="input-group input-group-sm">
<div class=" input-group-prepend">
<span class="input-group-text"><i class="fas fa-at"></i></span>
</div>
<input class="form-control form-control-sm" type="email" data-val="true" data-val-email="The Email field is not a valid e-mail address." data-val-required="The Email field is required." id="orderInformation_billTo_email"
name="orderInformation.billTo.email" value="">
<div class="input-group-append">
<div class="input-group-text input-group-sm-text bg-transparent border-0"> (for payment confirmation)</div>
</div>
</div>
<span class="text-danger small field-validation-valid" data-valmsg-for="orderInformation.billTo.email" data-valmsg-replace="true"></span>
</div>
</div>
</fieldset>
<fieldset class="border-bottom pb-3">
<legend class="font-weight-bold pt-3">Invoice Information</legend>
<div class="form-row">
<div class="form-group col-md-6">
<label class="col-form-label col-form-label-sm" for="clientReferenceInformation_code">Invoice Number<sup class="text-danger">*</sup></label>
<input type="number" class="form-control form-control-sm" data-val="true" data-val-maxlength="The field Invoice Number must be a string or array type with a maximum length of '8'." data-val-maxlength-max="8"
data-val-range="The field Invoice Number must be between 1 and 99999999." data-val-range-max="99999999" data-val-range-min="1" data-val-regex="Only numbers allowed" data-val-regex-pattern="^[0-9]*$"
data-val-required="The Invoice Number field is required." id="clientReferenceInformation_code" name="clientReferenceInformation.code" value="">
<div class="font-weight-bold">To receive proper credit, please pay each invoice separately.</div>
<span class="text-danger small field-validation-valid" data-valmsg-for="clientReferenceInformation.code" data-valmsg-replace="true"></span>
</div>
<div class="form-group col-md-6">
<label class="col-form-label col-form-label-sm" for="MerchantDefinedData3">Invoice Date<sup class="text-danger">*</sup></label>
<div class="input-group input-group-sm">
<input class="form-control form-control-sm datepicker hasDatepicker" readonly="readonly" type="text" data-val="true" data-val-required="The Invoice Date field is required." id="MerchantDefinedData3" name="MerchantDefinedData3" value=""
style="cursor: pointer; background-color: rgb(255, 255, 255);">
<div class="input-group-append">
<span class="input-group-text input-group-sm-text"><i class="fas fa-calendar-alt"></i></span>
</div>
</div>
<span class="text-danger small field-validation-valid" data-valmsg-for="MerchantDefinedData3" data-valmsg-replace="true"></span>
</div>
</div>
<div class="form-row">
<div class="form-group col-md-6">
<label class="col-form-label col-form-label-sm" for="orderInformation_amountDetails_invoiceAmount">Invoice Amount<sup class="text-danger">*</sup></label>
<div class="input-group input-group-sm">
<div class=" input-group-prepend">
<span class="input-group-text"><i class="fas fa-dollar-sign"></i></span>
</div>
<input type="number" class="form-control form-control-sm" data-val="true" data-val-number="The field Invoice Amount must be a number." data-val-range="The amount cannot be negative" data-val-range-max="1.7976931348623157E+308"
data-val-range-min="0" data-val-required="The Invoice Amount field is required." id="orderInformation_amountDetails_invoiceAmount" name="orderInformation.amountDetails.invoiceAmount" value="">
</div>
<span class="text-danger small field-validation-valid" data-valmsg-for="orderInformation.amountDetails.invoiceAmount" data-valmsg-replace="true"></span>
</div>
<div class="form-group col-md-6">
<label class="col-form-label col-form-label-sm" for="orderInformation_amountDetails_totalAmount">Payment Amount<sup class="text-danger">*</sup></label>
<div class="input-group input-group-sm">
<div class=" input-group-prepend">
<span class="input-group-text"><i class="fas fa-dollar-sign"></i></span>
</div>
<input type="number" class="form-control form-control-sm" data-val="true" data-val-number="The field Payment Amount must be a number." data-val-range="The amount cannot be negative" data-val-range-max="1.7976931348623157E+308"
data-val-range-min="0" data-val-required="The Payment Amount field is required." id="orderInformation_amountDetails_totalAmount" name="orderInformation.amountDetails.totalAmount" value="">
</div>
<span class="text-danger small field-validation-valid" data-valmsg-for="orderInformation.amountDetails.totalAmount" data-valmsg-replace="true"></span>
</div>
</div>
<div class="form-row">
<div class="form-group col-md-12">
<label class="col-form-label col-form-label-sm" for="MerchantDefinedData4">If <b>Invoice Amount</b> and <b>Payment Amount</b> differ, please explain:</label>
<textarea class="mw-100 form-control form-control-sm" id="MerchantDefinedData4" name="MerchantDefinedData4"></textarea>
<span class="text-danger small field-validation-valid" data-valmsg-for="MerchantDefinedData4" data-valmsg-replace="true"></span>
</div>
</div>
</fieldset>
<fieldset class="pb-3">
<legend class="font-weight-bold pt-3">Billing Information</legend>
<div class="form-row">
<div class="form-group col-md-6">
<label class="col-form-label col-form-label-sm" for="orderInformation_billTo_firstName">First Name<sup class="text-danger">*</sup></label>
<input class="form-control form-control-sm cc" placeholder="First Name" type="text" data-val="true" data-val-required="The First Name field is required." id="orderInformation_billTo_firstName" name="orderInformation.billTo.firstName"
value="">
<span class="text-danger small field-validation-valid" data-valmsg-for="orderInformation.billTo.firstName" data-valmsg-replace="true"></span>
</div>
<div class="form-group col-md-6">
<label class="col-form-label col-form-label-sm" for="orderInformation_billTo_lastName">Last Name<sup class="text-danger">*</sup></label>
<input class="form-control form-control-sm cc" placeholder="Last Name" type="text" data-val="true" data-val-required="The Last Name field is required." id="orderInformation_billTo_lastName" name="orderInformation.billTo.lastName" value="">
<span class="text-danger small field-validation-valid" data-valmsg-for="orderInformation.billTo.lastName" data-valmsg-replace="true"></span>
</div>
</div>
<div class="form-row">
<div class="form-group col-md-6">
<label class="col-form-label col-form-label-sm" for="orderInformation_billTo_address1">Address 1<sup class="text-danger">*</sup></label>
<input class="form-control form-control-sm" type="text" data-val="true" data-val-required="The Address 1 field is required." id="orderInformation_billTo_address1" name="orderInformation.billTo.address1" value="">
<span class="text-danger small field-validation-valid" data-valmsg-for="orderInformation.billTo.address1" data-valmsg-replace="true"></span>
</div>
<div class="form-group col-md-6">
<label class="col-form-label col-form-label-sm" for="orderInformation_billTo_address2">Address 2</label>
<input class="form-control form-control-sm" type="text" id="orderInformation_billTo_address2" name="orderInformation.billTo.address2" value="">
<span class="text-danger small field-validation-valid" data-valmsg-for="orderInformation.billTo.address2" data-valmsg-replace="true"></span>
</div>
</div>
<div class="form-row">
<div class="form-group col-md-3">
<label class="col-form-label col-form-label-sm" for="orderInformation_billTo_locality">City<sup class="text-danger">*</sup></label>
<input class="form-control form-control-sm" type="text" data-val="true" data-val-required="The City field is required." id="orderInformation_billTo_locality" name="orderInformation.billTo.locality" value="">
<span class="text-danger small field-validation-valid" data-valmsg-for="orderInformation.billTo.locality" data-valmsg-replace="true"></span>
</div>
<div class="form-group col-md-3">
<label class="col-form-label col-form-label-sm" for="orderInformation_billTo_administrativeArea">State<sup class="text-danger">*</sup></label>
<input class="form-control form-control-sm" type="text" data-val="true" data-val-required="The State field is required." id="orderInformation_billTo_administrativeArea" name="orderInformation.billTo.administrativeArea" value="">
<span class="text-danger small field-validation-valid" data-valmsg-for="orderInformation.billTo.administrativeArea" data-valmsg-replace="true"></span>
</div>
<div class="form-group col-md-3">
<label class="col-form-label col-form-label-sm" for="orderInformation_billTo_postalCode">Postal/Zip Code<sup class="text-danger">*</sup></label>
<input class="form-control form-control-sm" type="text" data-val="true" data-val-required="The Postal/Zip Code field is required." id="orderInformation_billTo_postalCode" name="orderInformation.billTo.postalCode" value="">
<span class="text-danger small field-validation-valid" data-valmsg-for="orderInformation.billTo.postalCode" data-valmsg-replace="true"></span>
</div>
<div class="form-group col-md-3">
<label class="col-form-label col-form-label-sm" for="orderInformation_billTo_country">Country<sup class="text-danger">*</sup></label>
<select id="slctCountry" class="form-control form-control-sm" name="orderInformation.billTo.country">
<option value="AF">Afghanistan</option>
<option value="AX">Åland Islands</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AS">American Samoa</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BY">Belarus</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia, Plurinational State of</option>
<option value="BQ">Bonaire, Sint Eustatius and Saba</option>
<option value="BA">Bosnia and Herzegovina</option>
<option value="BW">Botswana</option>
<option value="BV">Bouvet Island</option>
<option value="BR">Brazil</option>
<option value="IO">British Indian Ocean Territory</option>
<option value="BN">Brunei Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</option>
<option value="KY">Cayman Islands</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CG">Congo</option>
<option value="CD">Congo, the Democratic Republic of the</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="CI">Côte d'Ivoire</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CW">Curaçao</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands (Malvinas)</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="TF">French Southern Territories</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GU">Guam</option>
<option value="GT">Guatemala</option>
<option value="GG">Guernsey</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard Island and McDonald Islands</option>
<option value="VA">Holy See (Vatican City State)</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IR">Iran, Islamic Republic of</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IM">Isle of Man</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JE">Jersey</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KP">Korea, Democratic People's Republic of</option>
<option value="KR">Korea, Republic of</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Lao People's Democratic Republic</option>
<option value="LV">Latvia</option>
<option value="LB">Lebanon</option>
<option value="LS">Lesotho</option>
<option value="LR">Liberia</option>
<option value="LY">Libya</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macao</option>
<option value="MK">Macedonia, the Former Yugoslav Republic of</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MH">Marshall Islands</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia, Federated States of</option>
<option value="MD">Moldova, Republic of</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="ME">Montenegro</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="MM">Myanmar</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="MP">Northern Mariana Islands</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PS">Palestine, State of</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PN">Pitcairn</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RE">Réunion</option>
<option value="RO">Romania</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="BL">Saint Barthélemy</option>
<option value="SH">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="MF">Saint Martin (French part)</option>
<option value="PM">Saint Pierre and Miquelon</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="ST">Sao Tome and Principe</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="RS">Serbia</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SX">Sint Maarten (Dutch part)</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="GS">South Georgia and the South Sandwich Islands</option>
<option value="SS">South Sudan</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard and Jan Mayen</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syrian Arab Republic</option>
<option value="TW">Taiwan, Province of China</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania, United Republic of</option>
<option value="TH">Thailand</option>
<option value="TL">Timor-Leste</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option selected="selected" value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VE">Venezuela, Bolivarian Republic of</option>
<option value="VN">Viet Nam</option>
<option value="VG">Virgin Islands, British</option>
<option value="VI">Virgin Islands, U.S.</option>
<option value="WF">Wallis and Futuna</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select>
<span class="text-danger small field-validation-valid" data-valmsg-for="orderInformation.billTo.country" data-valmsg-replace="true"></span>
</div>
</div>
</fieldset>
<fieldset class="pb-3">
<p><span class="text-danger">*</span> Fields are required</p>
<p><strong>We have included a new feature to verify the above submission for payment. Please click the box below and follow the instructions to confirm acceptance</strong>.</p>
<div id="divCaptcha" class="g-recaptcha" data-sitekey="6Lc7v8MZAAAAAHuUISDrCDUYIVL37-Pvbp4Zk-PE">
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