provision.proforma.com Open in urlscan Pro
66.94.79.78  Public Scan

Form analysis
2 forms found in the DOM

<form class="form-horizontal ng-pristine ng-invalid ng-invalid-required ng-valid-maxlength ng-valid-date">
  <div class="form-group mt5 row"> <label class="col-4 h2-form">* Cardholder Name:</label>
    <div class="col-8"> <input ng-model="ccCtrl.ccInfo.CardholderName" type="text" class="form-control-req cardholdernameelement ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required ng-valid-maxlength" maxlength="50"
        name="Cardholder Name" id="CardholderName" required="" autocomplete="off"> </div>
  </div>
  <div class="form-group mt5 row"> <label class="col-4 h2-form">* Card Type:</label>
    <div class="col-8"> <label class="p mt5 ng-pristine ng-untouched ng-binding ng-empty ng-invalid ng-invalid-required" name="Card Type" id="CardType" ng-model="ccCtrl.ccInfo.CardType" required=""></label> </div>
  </div>
  <div class="form-group row"> <label class="col-4 h2-form">* Credit Card #:</label>
    <div class="col-8"> <input id="CreditCardNum" ng-model="ccCtrl.ccInfo.CreditCardNum" ng-blur="ccCtrl.setCreditCardType()" pro-numbers-only="" type="text"
        class="form-control-req ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required ng-valid-maxlength" maxlength="19" name="Credit Card Number" required="" autocomplete="off"> </div>
  </div>
  <div class="form-group row"> <label class="col-4 h2-form">* Expiration Date:</label>
    <div class="col-8"> <input type="text" placeholder="MM/YYYY" maxlength="7" class="form-control-req ng-pristine ng-untouched ng-isolate-scope ng-empty ng-invalid ng-invalid-required ng-valid-maxlength ng-valid-date" name="Expiration Date"
        id="ExpirationDate" ng-model="ccCtrl.ccInfo.ExpirationDate" is-open="ccCtrl.calendarOpen" ng-model-options="{updateOn: 'blur'}" uib-datepicker-popup="MM/yyyy"
        datepicker-template-url="procommon/views/ui-bootstrap/templates/datepicker/datepicker.html" datepicker-popup-template-url="procommon/views/ui-bootstrap/templates/datepickerpopup/popup.html" datepicker-options="{minMode: 'month'}"
        datepicker-mode="'month'" close-text="Close" mask-type="month" ng-required="true" required="required" autocomplete="off">
      <div uib-datepicker-popup-wrap="" ng-model="date" ng-change="dateSelection(date)" template-url="procommon/views/ui-bootstrap/templates/datepickerpopup/popup.html" class="ng-pristine ng-untouched ng-valid ng-scope ng-empty" style="">
        <!-- ngIf: isOpen --></div> <span class="fas fa-calendar-alt no-info calendar-in-form" ng-click="ccCtrl.calendarOpen = !ccCtrl.calendarOpen" aria-hidden="true"> </span>
    </div>
  </div>
  <div class="form-group row"> <label for="Security Code CCV/CID" class="col-4 h2-form">
      <a class="h2-form tip nounderline dashedUnderline"> * Security Code: <span class="tip-content security-code-placement"> <div class="container-fluid p-l-sm p-r-sm"> <div class="m-t-xs text-left black"> The Security Code is located as follows: </div> <ul> <li class="m-t-xs text-left black">American Express: The Security Code is the four-digit code printed on the front side of the card above the Credit Card Number.</li> <li class="m-t-xs text-left black">Discover, Master Card and Visa: The Security Code for both credit and debit cards is the three-digit number printed on the back side of the card at the far right of the signature panel.</li> </ul> <div class="mt10"> <img src="images/security_code_tooltip.png" alt="Security Code Information" width="450"> </div> </div> </span> </a>
    </label>
    <div class="col-8"> <input type="text" name="Security Code" id="SecurityCode" class="form-control-req ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required ng-valid-maxlength" ng-model="ccCtrl.ccInfo.SecurityCode" pro-numbers-only=""
        as-string="true" maxlength="4" required="" autocomplete="off"> </div>
  </div>
</form>

<form class="form-horizontal ng-pristine ng-invalid ng-invalid-required ng-valid-maxlength">
  <div class="form-group mt5 row"> <label class="col-3 h2-form">* Address:</label>
    <div class="col-8"> <input ng-model="ccCtrl.ccInfo.Address1" autocomplete="off" type="text" class="form-control-req ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required ng-valid-maxlength" maxlength="80" name="Address 1" id="Address1"
        required=""> </div>
  </div>
  <div class="form-group row"> <label class="col-3 h2-form">&nbsp;</label>
    <div class="col-8"> <input ng-model="ccCtrl.ccInfo.Address2" autocomplete="off" type="text" class="form-control-noreq ng-pristine ng-untouched ng-valid ng-empty ng-valid-maxlength" maxlength="80" name="Address 2" id="Address2"> </div>
  </div>
  <div class="form-group mt5 row"> <label class="col-3 h2-form">* City:</label>
    <div class="col-8"> <input ng-model="ccCtrl.ccInfo.City" type="text" class="form-control-req ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required ng-valid-maxlength" tabindex="-1" autocomplete="off" maxlength="40" name="City"
        id="City" required=""> </div>
  </div>
  <div class="form-group form-horizontal row"> <label type="text" class="col-3 h2-form"><!-- ngIf: !!ccCtrl.stateProvinceIsRequired(ccCtrl.ccInfo.Country) --><span ng-if="!!ccCtrl.stateProvinceIsRequired(ccCtrl.ccInfo.Country)" class="ng-scope"
        style="">* </span><!-- end ngIf: !!ccCtrl.stateProvinceIsRequired(ccCtrl.ccInfo.Country) -->State/Province:</label>
    <div class="col-4"> <input ng-model="ccCtrl.ccInfo.State" type="text" class="form-control-req ng-pristine ng-untouched ng-empty ng-valid-maxlength ng-invalid ng-invalid-required" tabindex="-1" autocomplete="off" maxlength="50" name="State"
        id="State" ng-class="!!ccCtrl.stateProvinceIsRequired(ccCtrl.ccInfo.Country) ? 'form-control-req' : 'form-control-noreq'" ng-required="!!ccCtrl.stateProvinceIsRequired(ccCtrl.ccInfo.Country)" required="required" style=""> </div> <label
      type="text" class="col-2 h2-form">* Postal Code:</label>
    <div class="col-2"> <pro-address pro-disable-broadcast="true" autocomplete="off" isrequired="true" is-required="true" pro-max-length="20" no-max-width="true" name="Postal Code" id="PostalCode" data-ng-model="ccCtrl.ccInfo.PostalCode"
        pro-city="ccCtrl.ccInfo.City" pro-state="ccCtrl.ccInfo.State" pro-postal-code="ccCtrl.ccInfo.PostalCode" pro-country-code="ccCtrl.ccInfo.Country.Id" pro-search-by-postal-code="true" selected-address="ccCtrl.ccInfo.PostalCode"
        class="ng-pristine ng-untouched ng-valid ng-isolate-scope ng-empty"><input type="text" ng-model="selectedAddress" id="PostalCode" name="Postal Code" ng-disabled="isDisabled" ng-change="undefined" autocomplete="off" pro-maxlength="20"
          ng-required="addIsReq()" placeholder="" style="max-width: 62px;; padding: 1px 6px;" typeahead-append-to-body="false" typeahead-select-on-blur="true" uib-typeahead="state as state.FormatedAddress for state in getAddressDetails($viewValue)"
          typeahead-on-select="OnSelect($item, $model, $label)" ng-class="addReqClass()" class="ng-pristine ng-untouched ng-scope ng-empty ng-invalid ng-invalid-required form-control-req form-control" aria-autocomplete="list" aria-expanded="false"
          aria-owns="typeahead-33-8241" required="required">
        <ul class="dropdown-menu ng-isolate-scope ng-hide" ng-show="isOpen() &amp;&amp; !moveInProgress" ng-style="{top: position().top+'px', left: position().left+'px'}" role="listbox" aria-hidden="true" uib-typeahead-popup="" id="typeahead-33-8241"
          matches="matches" active="activeIdx" select="select(activeIdx, evt)" move-in-progress="moveInProgress" query="query" position="position" assign-is-open="assignIsOpen(isOpen)" debounce="debounceUpdate">
          <!-- ngRepeat: match in matches track by $index -->
        </ul>
      </pro-address></div>
  </div>
  <div class="form-group row"> <label class="col-3 h2-form">* Country:</label>
    <div class="col-8"> <select class="form-control-req ng-pristine ng-untouched ng-not-empty ng-valid ng-valid-required" ng-model="ccCtrl.ccInfo.Country" autocomplete="off" ng-options="item.Name for item in ccCtrl.countries track by item.Id"
        name="Country" id="Country" ng-change="ccCtrl.checkUSOrCanada(ccCtrl.ccInfo.Country)" required="" style="">
        <option label="United States" value="1" selected="selected">United States</option>
        <option label="Canada" value="2">Canada</option>
        <option label="United Kingdom" value="3">United Kingdom</option>
        <option label="Afghanistan" value="4">Afghanistan</option>
        <option label="Albania" value="5">Albania</option>
        <option label="Algeria" value="6">Algeria</option>
        <option label="American Samoa" value="7">American Samoa</option>
        <option label="Andorra" value="8">Andorra</option>
        <option label="Angola" value="9">Angola</option>
        <option label="Anguilla" value="10">Anguilla</option>
        <option label="Antarctica" value="11">Antarctica</option>
        <option label="Antigua and Barbuda" value="12">Antigua and Barbuda</option>
        <option label="Argentina" value="13">Argentina</option>
        <option label="Armenia" value="14">Armenia</option>
        <option label="Aruba" value="15">Aruba</option>
        <option label="Australia" value="16">Australia</option>
        <option label="Austria" value="17">Austria</option>
        <option label="Azerbaijan" value="18">Azerbaijan</option>
        <option label="Bahamas" value="19">Bahamas</option>
        <option label="Bahrain" value="20">Bahrain</option>
        <option label="Bangladesh" value="21">Bangladesh</option>
        <option label="Barbados" value="22">Barbados</option>
        <option label="Belarus" value="23">Belarus</option>
        <option label="Belgium" value="24">Belgium</option>
        <option label="Belize" value="25">Belize</option>
        <option label="Benin" value="26">Benin</option>
        <option label="Bermuda" value="27">Bermuda</option>
        <option label="Bhutan" value="28">Bhutan</option>
        <option label="Bolivia" value="29">Bolivia</option>
        <option label="Bonaire" value="30">Bonaire</option>
        <option label="Bosnia and Herzegovina" value="31">Bosnia and Herzegovina</option>
        <option label="Botswana" value="32">Botswana</option>
        <option label="Bouvet Island" value="33">Bouvet Island</option>
        <option label="Brazil" value="34">Brazil</option>
        <option label="British Indian Ocean Territory" value="35">British Indian Ocean Territory</option>
        <option label="Brunei Darussalam" value="36">Brunei Darussalam</option>
        <option label="Bulgaria" value="37">Bulgaria</option>
        <option label="Burkina Faso" value="38">Burkina Faso</option>
        <option label="Burundi" value="39">Burundi</option>
        <option label="Cambodia" value="40">Cambodia</option>
        <option label="Cameroon" value="41">Cameroon</option>
        <option label="Cape Verde" value="42">Cape Verde</option>
        <option label="Cayman Islands" value="43">Cayman Islands</option>
        <option label="Central African Republic" value="44">Central African Republic</option>
        <option label="Chad" value="45">Chad</option>
        <option label="Chile" value="46">Chile</option>
        <option label="China" value="47">China</option>
        <option label="Christmas Island" value="48">Christmas Island</option>
        <option label="Cocos (Keeling) Islands" value="49">Cocos (Keeling) Islands</option>
        <option label="Colombia" value="50">Colombia</option>
        <option label="Comoros" value="51">Comoros</option>
        <option label="Congo" value="52">Congo</option>
        <option label="Democratic Republic of the Congo" value="53">Democratic Republic of the Congo</option>
        <option label="Cook Islands" value="54">Cook Islands</option>
        <option label="Costa Rica" value="55">Costa Rica</option>
        <option label="Croatia" value="56">Croatia</option>
        <option label="Cuba" value="57">Cuba</option>
        <option label="Curacao" value="58">Curacao</option>
        <option label="Cyprus" value="59">Cyprus</option>
        <option label="Czech Republic" value="60">Czech Republic</option>
        <option label="Cote d'Ivoire" value="61">Cote d'Ivoire</option>
        <option label="Denmark" value="62">Denmark</option>
        <option label="Djibouti" value="63">Djibouti</option>
        <option label="Dominica" value="64">Dominica</option>
        <option label="Dominican Republic" value="65">Dominican Republic</option>
        <option label="Ecuador" value="66">Ecuador</option>
        <option label="Egypt" value="67">Egypt</option>
        <option label="El Salvador" value="68">El Salvador</option>
        <option label="Equatorial Guinea" value="69">Equatorial Guinea</option>
        <option label="Eritrea" value="70">Eritrea</option>
        <option label="Estonia" value="71">Estonia</option>
        <option label="Ethiopia" value="72">Ethiopia</option>
        <option label="Falkland Islands (Malvinas)" value="73">Falkland Islands (Malvinas)</option>
        <option label="Faroe Islands" value="74">Faroe Islands</option>
        <option label="Fiji" value="75">Fiji</option>
        <option label="Finland" value="76">Finland</option>
        <option label="France" value="77">France</option>
        <option label="French Guiana" value="78">French Guiana</option>
        <option label="French Polynesia" value="79">French Polynesia</option>
        <option label="French Southern Territories" value="80">French Southern Territories</option>
        <option label="Gabon" value="81">Gabon</option>
        <option label="Gambia" value="82">Gambia</option>
        <option label="Georgia" value="83">Georgia</option>
        <option label="Germany" value="84">Germany</option>
        <option label="Ghana" value="85">Ghana</option>
        <option label="Gibraltar" value="86">Gibraltar</option>
        <option label="Greece" value="87">Greece</option>
        <option label="Greenland" value="88">Greenland</option>
        <option label="Grenada" value="89">Grenada</option>
        <option label="Guadeloupe" value="90">Guadeloupe</option>
        <option label="Guam" value="91">Guam</option>
        <option label="Guatemala" value="92">Guatemala</option>
        <option label="Guernsey" value="93">Guernsey</option>
        <option label="Guinea" value="94">Guinea</option>
        <option label="Guinea-Bissau" value="95">Guinea-Bissau</option>
        <option label="Guyana" value="96">Guyana</option>
        <option label="Haiti" value="97">Haiti</option>
        <option label="Heard Island and McDonald Mcdonald Islands" value="98">Heard Island and McDonald Mcdonald Islands</option>
        <option label="Holy See (Vatican City State)" value="99">Holy See (Vatican City State)</option>
        <option label="Honduras" value="100">Honduras</option>
        <option label="Hong Kong" value="101">Hong Kong</option>
        <option label="Hungary" value="102">Hungary</option>
        <option label="Iceland" value="103">Iceland</option>
        <option label="India" value="104">India</option>
        <option label="Indonesia" value="105">Indonesia</option>
        <option label="Iran, Islamic Republic of" value="106">Iran, Islamic Republic of</option>
        <option label="Iraq" value="107">Iraq</option>
        <option label="Ireland" value="108">Ireland</option>
        <option label="Isle of Man" value="109">Isle of Man</option>
        <option label="Israel" value="110">Israel</option>
        <option label="Italy" value="111">Italy</option>
        <option label="Jamaica" value="112">Jamaica</option>
        <option label="Japan" value="113">Japan</option>
        <option label="Jersey" value="114">Jersey</option>
        <option label="Jordan" value="115">Jordan</option>
        <option label="Kazakhstan" value="116">Kazakhstan</option>
        <option label="Kenya" value="117">Kenya</option>
        <option label="Kiribati" value="118">Kiribati</option>
        <option label="Korea, Democratic People's Republic of" value="119">Korea, Democratic People's Republic of</option>
        <option label="Korea, Republic of" value="120">Korea, Republic of</option>
        <option label="Kuwait" value="121">Kuwait</option>
        <option label="Kyrgyzstan" value="122">Kyrgyzstan</option>
        <option label="Lao People's Democratic Republic" value="123">Lao People's Democratic Republic</option>
        <option label="Latvia" value="124">Latvia</option>
        <option label="Lebanon" value="125">Lebanon</option>
        <option label="Lesotho" value="126">Lesotho</option>
        <option label="Liberia" value="127">Liberia</option>
        <option label="Libya" value="128">Libya</option>
        <option label="Liechtenstein" value="129">Liechtenstein</option>
        <option label="Lithuania" value="130">Lithuania</option>
        <option label="Luxembourg" value="131">Luxembourg</option>
        <option label="Macao" value="132">Macao</option>
        <option label="Macedonia, the Former Yugoslav Republic of" value="133">Macedonia, the Former Yugoslav Republic of</option>
        <option label="Madagascar" value="134">Madagascar</option>
        <option label="Malawi" value="135">Malawi</option>
        <option label="Malaysia" value="136">Malaysia</option>
        <option label="Maldives" value="137">Maldives</option>
        <option label="Mali" value="138">Mali</option>
        <option label="Malta" value="139">Malta</option>
        <option label="Marshall Islands" value="140">Marshall Islands</option>
        <option label="Martinique" value="141">Martinique</option>
        <option label="Mauritania" value="142">Mauritania</option>
        <option label="Mauritius" value="143">Mauritius</option>
        <option label="Mayotte" value="144">Mayotte</option>
        <option label="Mexico" value="145">Mexico</option>
        <option label="Micronesia, Federated States of" value="146">Micronesia, Federated States of</option>
        <option label="Moldova, Republic of" value="147">Moldova, Republic of</option>
        <option label="Monaco" value="148">Monaco</option>
        <option label="Mongolia" value="149">Mongolia</option>
        <option label="Montenegro" value="150">Montenegro</option>
        <option label="Montserrat" value="151">Montserrat</option>
        <option label="Morocco" value="152">Morocco</option>
        <option label="Mozambique" value="153">Mozambique</option>
        <option label="Myanmar" value="154">Myanmar</option>
        <option label="Namibia" value="155">Namibia</option>
        <option label="Nauru" value="156">Nauru</option>
        <option label="Nepal" value="157">Nepal</option>
        <option label="Netherlands" value="158">Netherlands</option>
        <option label="New Caledonia" value="159">New Caledonia</option>
        <option label="New Zealand" value="160">New Zealand</option>
        <option label="Nicaragua" value="161">Nicaragua</option>
        <option label="Niger" value="162">Niger</option>
        <option label="Nigeria" value="163">Nigeria</option>
        <option label="Niue" value="164">Niue</option>
        <option label="Norfolk Island" value="165">Norfolk Island</option>
        <option label="Northern Mariana Islands" value="166">Northern Mariana Islands</option>
        <option label="Norway" value="167">Norway</option>
        <option label="Oman" value="168">Oman</option>
        <option label="Pakistan" value="169">Pakistan</option>
        <option label="Palau" value="170">Palau</option>
        <option label="Palestine, State of" value="171">Palestine, State of</option>
        <option label="Panama" value="172">Panama</option>
        <option label="Papua New Guinea" value="173">Papua New Guinea</option>
        <option label="Paraguay" value="174">Paraguay</option>
        <option label="Peru" value="175">Peru</option>
        <option label="Philippines" value="176">Philippines</option>
        <option label="Pitcairn" value="177">Pitcairn</option>
        <option label="Poland" value="178">Poland</option>
        <option label="Portugal" value="179">Portugal</option>
        <option label="Puerto Rico" value="180">Puerto Rico</option>
        <option label="Qatar" value="181">Qatar</option>
        <option label="Romania" value="182">Romania</option>
        <option label="Russian Federation" value="183">Russian Federation</option>
        <option label="Rwanda" value="184">Rwanda</option>
        <option label="Reunion" value="185">Reunion</option>
        <option label="Saint Barthalemy" value="186">Saint Barthalemy</option>
        <option label="Saint Helena" value="187">Saint Helena</option>
        <option label="Saint Kitts and Nevis" value="188">Saint Kitts and Nevis</option>
        <option label="Saint Lucia" value="189">Saint Lucia</option>
        <option label="Saint Martin (French part)" value="190">Saint Martin (French part)</option>
        <option label="Saint Pierre and Miquelon" value="191">Saint Pierre and Miquelon</option>
        <option label="Saint Vincent and the Grenadines" value="192">Saint Vincent and the Grenadines</option>
        <option label="Samoa" value="193">Samoa</option>
        <option label="San Marino" value="194">San Marino</option>
        <option label="Sao Tome and Principe" value="195">Sao Tome and Principe</option>
        <option label="Saudi Arabia" value="196">Saudi Arabia</option>
        <option label="Senegal" value="197">Senegal</option>
        <option label="Serbia" value="198">Serbia</option>
        <option label="Seychelles" value="199">Seychelles</option>
        <option label="Sierra Leone" value="200">Sierra Leone</option>
        <option label="Singapore" value="201">Singapore</option>
        <option label="Sint Maarten (Dutch part)" value="202">Sint Maarten (Dutch part)</option>
        <option label="Slovakia" value="203">Slovakia</option>
        <option label="Slovenia" value="204">Slovenia</option>
        <option label="Solomon Islands" value="205">Solomon Islands</option>
        <option label="Somalia" value="206">Somalia</option>
        <option label="South Africa" value="207">South Africa</option>
        <option label="South Georgia and the South Sandwich Islands" value="208">South Georgia and the South Sandwich Islands</option>
        <option label="South Sudan" value="209">South Sudan</option>
        <option label="Spain" value="210">Spain</option>
        <option label="Sri Lanka" value="211">Sri Lanka</option>
        <option label="Sudan" value="212">Sudan</option>
        <option label="Suriname" value="213">Suriname</option>
        <option label="Svalbard and Jan Mayen" value="214">Svalbard and Jan Mayen</option>
        <option label="Swaziland" value="215">Swaziland</option>
        <option label="Sweden" value="216">Sweden</option>
        <option label="Switzerland" value="217">Switzerland</option>
        <option label="Syrian Arab Republic" value="218">Syrian Arab Republic</option>
        <option label="Taiwan, Province of China" value="219">Taiwan, Province of China</option>
        <option label="Tajikistan" value="220">Tajikistan</option>
        <option label="United Republic of Tanzania" value="221">United Republic of Tanzania</option>
        <option label="Thailand" value="222">Thailand</option>
        <option label="Timor-Leste" value="223">Timor-Leste</option>
        <option label="Togo" value="224">Togo</option>
        <option label="Tokelau" value="225">Tokelau</option>
        <option label="Tonga" value="226">Tonga</option>
        <option label="Trinidad and Tobago" value="227">Trinidad and Tobago</option>
        <option label="Tunisia" value="228">Tunisia</option>
        <option label="Turkey" value="229">Turkey</option>
        <option label="Turkmenistan" value="230">Turkmenistan</option>
        <option label="Turks and Caicos Islands" value="231">Turks and Caicos Islands</option>
        <option label="Tuvalu" value="232">Tuvalu</option>
        <option label="Uganda" value="233">Uganda</option>
        <option label="Ukraine" value="234">Ukraine</option>
        <option label="United Arab Emirates" value="235">United Arab Emirates</option>
        <option label="United States Minor Outlying Islands" value="236">United States Minor Outlying Islands</option>
        <option label="Uruguay" value="237">Uruguay</option>
        <option label="Uzbekistan" value="238">Uzbekistan</option>
        <option label="Vanuatu" value="239">Vanuatu</option>
        <option label="Venezuela" value="240">Venezuela</option>
        <option label="Viet Nam" value="241">Viet Nam</option>
        <option label="British Virgin Islands" value="242">British Virgin Islands</option>
        <option label="US Virgin Islands" value="243">US Virgin Islands</option>
        <option label="Wallis and Futuna" value="244">Wallis and Futuna</option>
        <option label="Western Sahara" value="245">Western Sahara</option>
        <option label="Yemen" value="246">Yemen</option>
        <option label="Zambia" value="247">Zambia</option>
        <option label="Zimbabwe" value="248">Zimbabwe</option>
        <option label="Åland Islands" value="250">Åland Islands</option>
        <option label="Netherlands Antilles" value="253">Netherlands Antilles</option>
        <option label="Serbia and Montenegro" value="254">Serbia and Montenegro</option>
        <option label="Canton and Enderbury Islands" value="255">Canton and Enderbury Islands</option>
        <option label="East Germany" value="256">East Germany</option>
        <option label="French Southern and Antarctic Territories" value="257">French Southern and Antarctic Territories</option>
        <option label="Metropolitan France" value="258">Metropolitan France</option>
        <option label="Johnston Island" value="259">Johnston Island</option>
        <option label="Midway Islands" value="260">Midway Islands</option>
        <option label="Dronning Maud Land" value="261">Dronning Maud Land</option>
        <option label="Neutral Zone" value="262">Neutral Zone</option>
        <option label="Pacific Islands Trust Territory" value="263">Pacific Islands Trust Territory</option>
        <option label="U.S. Miscellaneous Pacific Islands" value="264">U.S. Miscellaneous Pacific Islands</option>
        <option label="Panama Canal Zone" value="265">Panama Canal Zone</option>
        <option label="Union of Soviet Socialist Republics" value="266">Union of Soviet Socialist Republics</option>
        <option label="North Vietnam" value="267">North Vietnam</option>
        <option label="Wake Island" value="268">Wake Island</option>
        <option label="Peoples Democratic Republic of Yemen" value="269">Peoples Democratic Republic of Yemen</option>
        <option label="Unknown or Invalid Region" value="270">Unknown or Invalid Region</option>
        <option label="United States" value="271">United States</option>
      </select> </div>
  </div>
</form>

Text Content

PAY BILL BY CREDIT CARD


ALERT: THE RECIPIENT OF THIS CHARGE ON YOUR CREDIT CARD STATEMENT WILL BE
PFG*PROFORMA.

Bill # Bill Date Due Date Currency Bill Total Payment Due * Payment BS21067797A
11/22/2022 12/21/2022 USD 2,108.60 2,108.60


CREDIT CARD AND BILLING ADDRESS INFORMATION: FOR PRIVACY AND SECURITY PURPOSES,
YOU MUST ALWAYS REENTER THE INFORMATION BELOW. PLEASE ENTER INFORMATION AS IT
APPEARS ON YOUR CREDIT CARD STATEMENT.

* Cardholder Name:

* Card Type:

* Credit Card #:

* Expiration Date:

* Security Code:
The Security Code is located as follows:
 * American Express: The Security Code is the four-digit code printed on the
   front side of the card above the Credit Card Number.
 * Discover, Master Card and Visa: The Security Code for both credit and debit
   cards is the three-digit number printed on the back side of the card at the
   far right of the signature panel.



* Address:

 

* City:

* State/Province:

* Postal Code:

* Country:
United StatesCanadaUnited KingdomAfghanistanAlbaniaAlgeriaAmerican
SamoaAndorraAngolaAnguillaAntarcticaAntigua and
BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaireBosnia
and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei
DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman
IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling)
IslandsColombiaComorosCongoDemocratic Republic of the CongoCook IslandsCosta
RicaCroatiaCubaCuracaoCyprusCzech RepublicCote
d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl
SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe
IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern
TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard
Island and McDonald Mcdonald IslandsHoly See (Vatican City State)HondurasHong
KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsle of
ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic
People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic
RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia,
the Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall
IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States
ofMoldova, Republic
ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew
CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana
IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New
GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto
RicoQatarRomaniaRussian FederationRwandaReunionSaint BarthalemySaint HelenaSaint
Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and
MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and
PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten
(Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and
the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan
MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of
ChinaTajikistanUnited Republic of
TanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and
TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited
Arab EmiratesUnited States Minor Outlying
IslandsUruguayUzbekistanVanuatuVenezuelaViet NamBritish Virgin IslandsUS Virgin
IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweÅland
IslandsNetherlands AntillesSerbia and MontenegroCanton and Enderbury IslandsEast
GermanyFrench Southern and Antarctic TerritoriesMetropolitan FranceJohnston
IslandMidway IslandsDronning Maud LandNeutral ZonePacific Islands Trust
TerritoryU.S. Miscellaneous Pacific IslandsPanama Canal ZoneUnion of Soviet
Socialist RepublicsNorth VietnamWake IslandPeoples Democratic Republic of
YemenUnknown or Invalid RegionUnited States


OTHER INFORMATION

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NOTES:




THANK YOU FOR YOUR BUSINESS!

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