app.benjipays.com Open in urlscan Pro
44.239.74.124  Public Scan

Form analysis
1 forms found in the DOM

POST /portal/paynow/moneris/submit

<form class="card-request-form card-request-form-moneris card-request-form-62b5de78ffb08a06d9015c6b" id="card-request-form-moneris-1e25a919a" method="post" action="/portal/paynow/moneris/submit" data-trans-type="cc">
  <div class="form-group">
    <label for="companyName" class="form-label">Customer / Company Name*</label>
    <input type="text" name="companyName" id="companyName" class="form-control" placeholder="Customer / Company Name*" maxlength="200" required="" value="">
  </div>
  <div class="form-group">
    <label for="invoiceNumber" class="form-label">Invoice / Reference Number*</label>
    <input type="text" name="invoiceNumber" id="invoiceNumber" class="form-control" placeholder="Invoice / Reference Number*" maxlength="100" required="" value="">
  </div>
  <div class="form-group">
    <label for="paymentAmount" class="form-label">Payment Amount (CAD)*</label>
    <div class="input-group">
      <span class="input-group-text currency-symbol">$</span>
      <input id="paymentAmount" name="paymentAmount" class="form-control" data-inputmask="'alias': 'numeric', 'groupSeparator': '', 'autoGroup': false, 'digits': 2, 'digitsOptional': false, 'placeholder': '0'" required="" value="" inputmode="decimal"
        style="text-align: right;">
    </div>
  </div>
  <div class="form-group">
    <label for="billing_name" class="form-label">Name on Card*</label>
    <input type="text" name="billing_name" id="billing_name" class="form-control" placeholder="Name on Card*" autocomplete="cc-name" maxlength="100" required="">
  </div>
  <!-- <div class="form-row" style="padding-top: 10px;">  
    <label for="phone">Phone Number <small class="text-muted">(Optional)</small></label>
    <input type="phone" name="phone" id="phone" class="form-control phone" data-inputmask="'mask': '(999) 999-9999'" placeholder="Phone Number" autocomplete="tel" maxlength="14" >
  </div> -->
  <div class="form-group email-row" style="padding-top: 10px;">
    <label for="email" id="email_label" class="form-label">Email Address*</label>
    <input type="email" name="email" id="email" class="form-control email" placeholder="Email Address*" autocomplete="email" required="required">
  </div>
  <div class="form-group" style="padding-bottom: 10px; padding-top: 10px;">
    <label for="credit_card" class="form-label">Credit Card Number*</label>
    <div>
      <iframe id="monerisFrame"
        src="https://www3.moneris.com/HPPtoken/index.php?id=htOTDSYNGNHU7MV&amp;
        pmmsg=true&amp;display_labels=0&amp;
        enable_exp=0&amp;
        enable_cvd=0&amp;
        css_textbox_pan=display%3A%20block%3Bwidth%3A%20100%25%3Bheight%3A%20calc%281.5em%20%2B%20.75rem%20%2B%202px%29%3Bpadding%3A%20.375rem%20.75rem%3Bfont-size%3A%201rem%3Bfont-weight%3A%20400%3Bline-height%3A%201.5rem%3Bcolor%3A%20%23495057%3Bbackground-color%3A%20%23fff%3Bbackground-clip%3A%20padding-box%3Bborder%3A%201px%20solid%20%23ced4da%3Bborder-radius%3A%20.25rem%3Btransition%3A%20border-color%20.15s%20ease-in-out%2Cbox-shadow%20.15s%20ease-in-out%3B&amp;"
        frameborder="0" width="100%" height="40px">
      </iframe>
      <div class="form-text">Numbers Only. No spaces, dashes or any other characters.</div>
    </div>
    <div id="monerisResponse" hidden=""></div>
  </div>
  <div class="form-group col-md-8">
    <label class="form-label">Expiry Date*</label>
    <div class="input-group col-sm-4">
      <select name="exp_month" id="exp_month" class="form-select exp_month" placeholder="" autocomplete="cc-exp-month" required="">
        <option value="">Month</option>
        <option>01</option>
        <option>02</option>
        <option>03</option>
        <option>04</option>
        <option>05</option>
        <option>06</option>
        <option>07</option>
        <option>08</option>
        <option>09</option>
        <option>10</option>
        <option>11</option>
        <option>12</option>
      </select>&nbsp;&nbsp; <select name="exp_year" id="exp_year" class="form-select exp_year" placeholder="" autocomplete="cc-exp-year" required="">
        <option value="">Year</option>
        <option>24</option>
        <option>25</option>
        <option>26</option>
        <option>27</option>
        <option>28</option>
        <option>29</option>
        <option>30</option>
        <option>31</option>
        <option>32</option>
        <option>33</option>
        <option>34</option>
      </select>
    </div>
  </div>
  <div class="form-group col-sm-4">
    <label for="cvv" class="form-label">CVC*</label>
    <input type="number" name="cvv" id="cvv" class="form-control cvv" placeholder="CVC" maxlength="4" autocomplete="cc-csc" required="">
  </div>
  <div id="authorization-group" class="mb-4" hidden="hidden">
    <div class="form-group">
      <label class="form-label">Payment Authorization</label>
    </div>
    <textarea class="form-control col-xs-12" rows="5" style="width: 100%;"
      disabled="">I hereby authorize Tech Fuel Inc. the use of my credit card for automatic withdrawals from my account for purchases made. I understand that my information will be saved on file for future transactions on my account. I understand that the credit card information listed above is being relied upon for payment as authorized of all sales of goods and or services in accordance with the terms stated on the order(s)and invoice(s). The failure to pay on or before the due date of each invoice shall deem the debt to the delinquent. In the event of delinquency, all collection expenses, including agency fees and costs, attorney’s fees and  or court costs incurred in connection with the collection of the debt shall be payable by the business and the authorized card holder.</textarea>
  </div>
  <div class="form-group agree-checks">
    <div class="form-check agree-check-group" hidden="">
      <input type="checkbox" class="form-check-input agree-checkbox" id="agree-1e25a919a" name="agree" value="1">
      <label class="form-check-label" for="agree-1e25a919a">I have read and agree to the payment authorization terms above.*</label>
    </div>
  </div>
  <div class="bp-recaptcha recaptcha-size-invisible" data-recaptcha-sitekey="6LcECrEfAAAAAM--PFuC_ehVo3sOi-Jg5C3PCshY" data-recaptcha-size="invisible" data-recaptcha-visible-class="form-group">
    <div class="grecaptcha-badge" data-style="bottomright" style="width: 256px; height: 60px; display: block; transition: right 0.3s; position: fixed; bottom: 14px; right: -186px; box-shadow: gray 0px 0px 5px; border-radius: 2px; overflow: hidden;">
      <div class="grecaptcha-logo"><iframe title="reCAPTCHA" width="256" height="60" role="presentation" name="a-ldwao7gy3czw" frameborder="0" scrolling="no"
          sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox allow-storage-access-by-user-activation"
          src="https://www.google.com/recaptcha/api2/anchor?ar=1&amp;k=6LcECrEfAAAAAM--PFuC_ehVo3sOi-Jg5C3PCshY&amp;co=aHR0cHM6Ly9hcHAuYmVuamlwYXlzLmNvbTo0NDM.&amp;hl=en&amp;v=-ZG7BC9TxCVEbzIO2m429usb&amp;size=invisible&amp;cb=h2hj0zez56ia"></iframe>
      </div>
      <div class="grecaptcha-error"></div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response"
        style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
    </div><iframe style="display: none;"></iframe>
  </div>
  <div class="processing-errors"></div>
  <div class="form-group">
    <button type="submit" class="btn btn-primary btn-submit w-100">Submit</button>
    <button class="btn btn-primary btn-processing w-100" type="button" disabled="" hidden="">
      <span class="spinner-border spinner-border-sm" role="status" aria-hidden="true"></span> Processing... </button>
  </div>
  <input type="hidden" name="_csrf" value="SjuH3U4q-ySGP0ayu4dFwl5Fdtp7OUzt18K8">
  <input type="hidden" name="gid" id="gid" value="62b5de78ffb08a06d9015c6b">
  <input type="hidden" name="subdomain" id="subdomain" value="techfuel">
  <input type="hidden" name="shortcode" id="shortcode" value="">
  <input type="hidden" name="noinv" id="noinv" value="true">
  <input type="hidden" name="currency" id="currency" value="CAD">
  <input type="hidden" name="requestid" id="requestid" value="">
  <input type="hidden" name="invoice_id" value="">
  <input type="hidden" name="bin" id="bin">
  <input type="hidden" name="ctype" id="ctype">
  <input type="hidden" name="tempToken" id="tempToken">
</form>

Text Content

Language English Français
Pay with a new card
Customer / Company Name*
Invoice / Reference Number*
Payment Amount (CAD)*
$
Name on Card*
Email Address*
Credit Card Number*
Numbers Only. No spaces, dashes or any other characters.

Expiry Date*
Month 01 02 03 04 05 06 07 08 09 10 11 12    Year 24 25 26 27 28 29 30 31 32 33
34
CVC*
Payment Authorization
I hereby authorize Tech Fuel Inc. the use of my credit card for automatic
withdrawals from my account for purchases made. I understand that my information
will be saved on file for future transactions on my account. I understand that
the credit card information listed above is being relied upon for payment as
authorized of all sales of goods and or services in accordance with the terms
stated on the order(s)and invoice(s). The failure to pay on or before the due
date of each invoice shall deem the debt to the delinquent. In the event of
delinquency, all collection expenses, including agency fees and costs,
attorney’s fees and or court costs incurred in connection with the collection of
the debt shall be payable by the business and the authorized card holder.
I have read and agree to the payment authorization terms above.*


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