traveljoy.com Open in urlscan Pro
54.193.246.45  Public Scan

Form analysis
1 forms found in the DOM

POST /invoices/NYyWyArGr7hU7veEP33Dv7Dt/client/authorize

<form class="edit_invoice" id="client-submit-questionnaire-form" action="/invoices/NYyWyArGr7hU7veEP33Dv7Dt/client/authorize" accept-charset="UTF-8" method="post" novalidate="novalidate"><input type="hidden" name="authenticity_token"
    value="nFiTwvXVNqPjEoEN+Bb7Kt5GwpcV5DxEIrf3qWXSHodqR24m37BxOjh71maLyZB0YWgJG7gbjP4zUIdMEcImxg==" autocomplete="off">
  <div class="panel panel-default supplier-invoice">
    <div class="panel-body">
      <div class="row">
        <div class="col-sm-12">
          <div class="bg-picture bg-picture-cover-photo p-t-15" style="background-image:url(https://s3-assets.traveljoy.com/trip_photos/photos/000/053/965/large/9638a3bcc6943ae707524dfeef8b0e62cb45190c.jpg?1611357647);">
            <span class="bg-picture-overlay"></span>
            <div class="box-layout meta bottom trip-details-container">
              <div class="col-sm-6 clearfix text-left pull-top-xs pull-bottom-sm">
                <span class="img-wrapper pull-left m-r-15"><img src="https://s3-assets.traveljoy.com/users/agency_logos/000/024/744/medium/0cc20d8e50d003995a71a58796ec739e07100ba4.jpg?1633974807" alt="agency logo" style="height: 64px;"
                    class="br-radius"></span>
                <div class="media-body">
                  <h3 class="text-white mb-2 m-t-10 ellipsis">Laura Morillo</h3>
                  <h5 class="text-white">Piedmont Travel</h5>
                </div>
              </div>
              <div class="col-sm-6 clearfix text-right pull-bottom-xs pull-bottom-sm trip-details-container-trip-info">
                <div class="media-body">
                  <h3 class="text-white mb-2 m-t-10 ellipsis">Joy Brown's Trip</h3>
                  <h5 class="text-white"></h5>
                  <h5 class="text-white">Joy &amp; Brian Brown</h5>
                  <h5 class="text-white"></h5>
                  <h5 class="text-white"></h5>
                </div>
              </div>
            </div>
          </div>
        </div>
      </div>
      <br>
      <br>
      <div class="clearfix">
        <div class="pull-left">
          <h4>Piedmont Travel</h4>
          <address class="m-b-0">
            <p>144 North Cherry St <br>St 2 <br>Kernersville, NC 27284</p> 3369922828
          </address>
        </div>
        <div class="pull-right">
          <h4 id="invoice-num">Invoice #<strong>INV-890099</strong></h4>
        </div>
      </div>
      <hr>
      <div class="row">
        <div class="col-sm-12 visible-xs-block visible-sm-block m-b-20">
          <p><strong>Invoice Date: </strong>December 19, 2022</p>
          <p class="m-t-10"><strong>To: </strong>Joy Slate Brown</p>
          <p class="m-t-10"><strong>Email: </strong>joy.brown@novanthealth.org</p>
          <p class="m-t-10"><strong>Status: </strong><span class="label label-warning text-uppercase">unpaid</span></p>
        </div>
        <div class="col-sm-12 col-md-8">
        </div>
        <div class="col-md-4 hidden-xs hidden-sm">
          <div class="pull-right">
            <p><strong>Invoice Date: </strong>December 19, 2022</p>
            <p class="m-t-10"><strong>To: </strong>Joy Slate Brown</p>
            <p class="m-t-10"><strong>Email: </strong>joy.brown@novanthealth.org</p>
            <p class="m-t-10"><strong>Status: </strong><span class="label label-warning text-uppercase">unpaid</span></p>
          </div>
        </div>
      </div>
      <hr>
      <div class="row">
        <div class="col-md-12">
          <div class="table-responsive">
            <table class="table m-t-30 preview-invoice-items-table">
              <thead>
                <tr>
                  <th>Item</th>
                  <th>Description</th>
                  <th>Quantity</th>
                  <th>Price</th>
                  <th>Total</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>Package</td>
                  <td>
                    <div class="invoice-item-description">
                      <div>Itinerary per Approved Proposal</div>
                    </div>
                    <table class="invoice-item-description-table m-t-5">
                      <thead></thead>
                      <tbody>
                        <tr>
                          <td><b>Start:</b></td>
                          <td>03/05/2023</td>
                        </tr>
                        <tr>
                          <td><b>End:</b></td>
                          <td>03/10/2023</td>
                        </tr>
                      </tbody>
                    </table>
                  </td>
                  <td>1</td>
                  <td>$4,674.78</td>
                  <td>$4,674.78</td>
                </tr>
              </tbody>
            </table>
          </div>
        </div>
      </div>
      <div class="row" style="border-radius: 0px;">
        <div class="col-md-6 col-md-offset-6 m-t-15">
          <h4 id="invoice-total-amount" class="text-right" style="font-size: 16px;"> Total Amount: $4,674.78 </h4>
          <h4 id="invoice-total-payments" class="text-right" style="font-size: 16px;"> Payments/Credits: -$400.00 </h4>
          <hr>
          <h3 id="invoice-balance-due" class="text-right" data-balance-due="4274.78" data-balance-due-formatted="$4,274.78"> Amount Due: $4,274.78 <span class="invoice-balance-amount"> / $4,274.78 </span>
          </h3>
        </div>
      </div>
      <hr>
      <div class="page-break"></div>
      <h2 class="m-b-15">Credit Card Authorization</h2>
      <div class="cc-auth-v2-section p-30-md p-20-sm ">
        <div class="row hidden-sm hidden-xs">
          <div class="col-md-1 max-width-35">
            <span class="step-num p-l-6-5">1</span>
          </div>
          <div class="col-md-11">
            <label>Enter the amount you would like to authorize:</label>
          </div>
        </div>
        <div class="row visible-sm visible-xs text-center m-t-10">
          <div class="col-md-12">
            <div class="row">
              <div class="col-md-12">
                <span class="step-num">1</span>
              </div>
            </div>
            <div class="row m-t-5">
              <div class="col-md-12">
                <label>Enter the amount you would like to authorize:</label>
              </div>
            </div>
          </div>
        </div>
        <div class="row m-t-10">
          <div class="col-md-1 max-width-35"></div>
          <div class="col-md-11">
            <label id="amount-selector-error" class="error" for="amount-selector" style="display: none;"></label>
            <div class="radio">
              <label>
                <input type="radio" name="amount-selector" required="" id="4274.78" value="4274.78"> $4,274.78 - Amount due </label>
            </div>
            <div class="radio">
              <label>
                <input type="radio" name="amount-selector" required="" id="4274.78" value="4274.78"> $4,274.78 - Remaining balance </label>
            </div>
            <div class="radio">
              <label>
                <input type="radio" name="amount-selector" required="" id="other" value="other"> Other amount </label>
            </div>
            <div class="input-group"><span class="input-group-addon"><i class="glyphicon glyphicon-usd"></i></span><input type="text" name="custom-amount" class="form-control" id="custom-amount"
                data-msg="Enter an amount between $0.01 and $4,274.78. Use only numbers and a decimal point (no currency signs, commas, or spaces)." disabled="" required="" min="0.01" max="4274.78" aria-required="true" value=""
                placeholder="ex: 100.00"></div><label class="error" for="custom-amount" style="display: none;"></label>
            <input type="hidden" name="amount" id="amount">
          </div>
        </div>
        <div class="row m-t-25">
          <div class="col-md-12">
            <div class="row hidden-xs hidden-sm">
              <div class="col-md-1 max-width-35">
                <span class="step-num p-l-6-5">2</span>
              </div>
              <div class="col-md-11">
                <label>Please add or choose card to authorize:</label>
              </div>
            </div>
            <div class="row visible-sm visible-xs text-center">
              <div class="col-md-12">
                <div class="row">
                  <div class="col-md-12">
                    <span class="step-num">2</span>
                  </div>
                </div>
                <div class="row m-t-5">
                  <div class="col-md-12">
                    <label>Please add or choose card to authorize:</label>
                  </div>
                </div>
              </div>
            </div>
            <div class="row">
              <div class="col-md-1 max-width-35"></div>
              <div class="col-md-11">
                <div class="credit-card-auth-container">
                  <div class="before-entering-credit-card" style="display: block;">
                    <div class="existing-credit-cards" style="display: block;">
                      <label class="error" for="questionnaire[client_credit_card][id]" style="display: none;"></label>
                      <div class="radio">
                        <label for="client_credit_card_id_555449">
                          <input type="radio" id="client_credit_card_id_555449" name="questionnaire[client_credit_card][id]" value="555449" data-name-on-card="Joy S Brown" data-get-security-code="false"
                            data-get-security-code-path="/clients/HxhN31EVJRsx7Ya44PC4QtHA/client_credit_cards/svVbqL3TqZSohh1UEMph44rV/get_security_code" data-msg="A credit card is required."> Visa ending in 3842 expires 05/27 </label>
                      </div>
                    </div>
                    <input autocomplete="off" type="hidden" name="questionnaire[client_credit_card][last_4]" id="questionnaire_client_credit_card_last_4">
                    <input autocomplete="off" type="hidden" name="questionnaire[client_credit_card][card_type]" id="questionnaire_client_credit_card_card_type">
                    <input data-msg="A credit card is required." autocomplete="off" type="hidden" name="questionnaire[client_credit_card][tokenex_card_number_token]" id="questionnaire_client_credit_card_tokenex_card_number_token">
                    <input autocomplete="off" type="hidden" name="questionnaire[client_credit_card][tokenex_security_code_token]" id="questionnaire_client_credit_card_tokenex_security_code_token">
                    <input autocomplete="off" type="hidden" name="questionnaire[client_credit_card][expiration_date]" id="questionnaire_client_credit_card_expiration_date">
                    <input autocomplete="off" type="hidden" name="questionnaire[client_credit_card][name_on_card]" id="questionnaire_client_credit_card_name_on_card">
                    <input autocomplete="off" type="hidden" name="questionnaire[client_credit_card][billing_phone_number]" id="questionnaire_client_credit_card_billing_phone_number">
                    <input autocomplete="off" type="hidden" name="questionnaire[client_credit_card][address_attributes][line_1]" id="questionnaire_client_credit_card_address_attributes_line_1">
                    <input autocomplete="off" type="hidden" name="questionnaire[client_credit_card][address_attributes][line_2]" id="questionnaire_client_credit_card_address_attributes_line_2">
                    <input autocomplete="off" type="hidden" name="questionnaire[client_credit_card][address_attributes][city]" id="questionnaire_client_credit_card_address_attributes_city">
                    <input autocomplete="off" type="hidden" name="questionnaire[client_credit_card][address_attributes][state]" id="questionnaire_client_credit_card_address_attributes_state">
                    <input autocomplete="off" type="hidden" name="questionnaire[client_credit_card][address_attributes][zip]" id="questionnaire_client_credit_card_address_attributes_zip">
                    <div class="btn-group btn-block-sm m-t-15 m-t-10-sm-xs hidden-print">
                      <button name="button" type="button" class="btn btn-block btn-default" data-toggle="modal" data-target="#enter-credit-card-modal">add new credit card</button>
                    </div>
                    <div>
                      <label class="error" for="questionnaire_client_credit_card_tokenex_card_number_token" style="display: none;"></label>
                    </div>
                  </div>
                  <div class="after-entering-credit-card" style="display: none;">
                    <div class="row">
                      <div class="col-md-12">
                        <div class="well">
                          <div class="form-group">
                            <label class="control-label" for="card_description">Card description*</label>
                            <input type="text" name="questionnaire[client_credit_card][card_description]" id="questionnaire_client_credit_card_card_description" value="" class="form-control card-description" placeholder="ex: Chase preferred">
                          </div>
                          <p>
                            <span class="vertical-align-middle m-r-5 fa fa-cc-visa credit-card-logo" aria-hidden="true"></span>
                            <span class="vertical-align-middle">
                              <span class="card-type"></span> ending in <span class="last-4"></span> expires <span class="expiration-date"></span>
                            </span>
                          </p>
                        </div>
                      </div>
                    </div>
                  </div>
                </div>
              </div>
            </div>
          </div>
        </div>
        <div class="row m-t-25">
          <div class="col-md-12">
            <div class="row hidden-xs hidden-sm">
              <div class="col-md-1 max-width-35">
                <span class="step-num p-l-6-5">3</span>
              </div>
              <div class="col-md-11">
                <label>Sign and agree to the terms and conditions:</label>
              </div>
            </div>
            <div class="row visible-xs visible-sm text-center">
              <div class="col-md-12">
                <div class="row">
                  <div class="col-md-12">
                    <span class="step-num">3</span>
                  </div>
                </div>
                <div class="row m-t-5">
                  <div class="col-md-12">
                    <label>Sign and agree to the terms and conditions:</label>
                  </div>
                </div>
              </div>
            </div>
            <div class="row m-t-10">
              <div class="col-md-1 max-width-35"></div>
              <div class="col-md-11 col-xs-12">
                <div class="read-more-container">
                  <div class="read-more-content">
                    <p>By signing below, I authorize Piedmont Travel to charge the credit card provided herein.</p>
                  </div>
                  <div class="read-more" style="display: none;"><a href="#" class="btn btn-default">read more</a></div>
                </div>
              </div>
            </div>
          </div>
        </div>
        <div class="row">
          <div class="col-md-1 max-width-35"></div>
          <div class="col-md-11 col-xs-12">
            <div id="click-to-sign-signature-box" data-target="#client-signature-modal" data-toggle="modal" style="display: block;">
              <p>Click to sign</p>
            </div>
            <div id="signature-photo-container" style="display: none;">
              <img src="">
            </div>
            <div id="signature-text-container" style="display: none;">
              <span class="signature-text"></span>
            </div>
            <label class="error signature-type-error" for="signature_type" style="display: none;"></label>
            <div class="name-under-signature">
              <div class="pull-left" id="signature-name"></div>
              <div id="signed-at-text" class="pull-right"><strong></strong></div>
            </div>
            <input type="hidden" name="signature_data_url" id="signature_data_url" autocomplete="off">
            <input type="hidden" name="signature_text" id="signature_text" autocomplete="off">
            <input type="hidden" name="signature_type" id="signature_type" required="required" data-msg="A signature is required." autocomplete="off">
            <input type="hidden" name="electronic_signature_agreed" id="electronic_signature_agreed" required="required" data-msg="Electronic signature agreement is required." autocomplete="off">
          </div>
        </div>
        <div class="row m-t-40 hidden-sm hidden-xs">
          <div class="col-md-12 p-l-30">
            <h4 class="text-center">Click the “AUTHORIZE PAYMENT” button to submit</h4>
            <div class="text-center">
              <a type="button" class="btn btn-primary btn-submit-questionnaire">authorize payment</a>
            </div>
          </div>
        </div>
      </div>
    </div>
  </div>
  <div class="page-break"></div>
  <div class="panel panel-default invoice-payment-schedule pdf-nobreak">
    <div class="panel-heading">
      <h3 class="panel-title">Payment Schedule</h3>
    </div>
    <div class="panel-body">
      <div class="row">
        <div class="col-md-12">
          <div class="table-responsive">
            <table class="table m-t-30">
              <thead>
                <tr>
                  <th>Status</th>
                  <th>Invoice #</th>
                  <th>Due Date</th>
                  <th>Description</th>
                  <th>Amount</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>
                    <span style="text-transform: uppercase;" class="label label-success">paid</span>
                  </td>
                  <td>INV-890099-0001</td>
                  <td>Dec 19, 2022</td>
                  <td>Deposit</td>
                  <td>$400.00</td>
                </tr>
                <tr>
                  <td>
                    <span style="text-transform: uppercase;" class="label label-warning">unpaid</span>
                  </td>
                  <td>INV-890099-0002</td>
                  <td>Jan 20, 2023</td>
                  <td>Final Payment</td>
                  <td>$4,274.78</td>
                </tr>
              </tbody>
            </table>
          </div>
        </div>
      </div>
    </div>
  </div> <!-- panel -->
</form>

Text Content

×

CREATE TRIP


LOADING...

×

CREATE GROUP


LOADING...

 1. Joy Brown's Trip
 2. Invoice


    JAMAICA PACKAGE

 * ask a question
 * Authorize payment

 * type
 * draw

×

By signing, I understand that this is a legally binding contract.
sign
×

ENTER CREDIT CARD

--------------------------------------------------------------------------------

Card number

Name on card

Expiration date


Security Code

Billing phone

Billing address






Secure connection

save credit card




LAURA MORILLO

PIEDMONT TRAVEL


JOY BROWN'S TRIP



JOY & BRIAN BROWN







PIEDMONT TRAVEL

144 North Cherry St
St 2
Kernersville, NC 27284

3369922828

INVOICE #INV-890099

--------------------------------------------------------------------------------

Invoice Date: December 19, 2022

To: Joy Slate Brown

Email: joy.brown@novanthealth.org

Status: unpaid



Invoice Date: December 19, 2022

To: Joy Slate Brown

Email: joy.brown@novanthealth.org

Status: unpaid

--------------------------------------------------------------------------------

Item Description Quantity Price Total Package
Itinerary per Approved Proposal

Start: 03/05/2023 End: 03/10/2023

1 $4,674.78 $4,674.78

TOTAL AMOUNT: $4,674.78

PAYMENTS/CREDITS: -$400.00

--------------------------------------------------------------------------------


AMOUNT DUE: $4,274.78 / $4,274.78

--------------------------------------------------------------------------------




CREDIT CARD AUTHORIZATION

1
Enter the amount you would like to authorize:
1
Enter the amount you would like to authorize:
$4,274.78 - Amount due
$4,274.78 - Remaining balance
Other amount

2
Please add or choose card to authorize:
2
Please add or choose card to authorize:
Visa ending in 3842 expires 05/27
add new credit card

Card description*

ending in expires

3
Sign and agree to the terms and conditions:
3
Sign and agree to the terms and conditions:

By signing below, I authorize Piedmont Travel to charge the credit card provided
herein.

read more

Click to sign





CLICK THE “AUTHORIZE PAYMENT” BUTTON TO SUBMIT

authorize payment



PAYMENT SCHEDULE

Status Invoice # Due Date Description Amount paid INV-890099-0001 Dec 19, 2022
Deposit $400.00 unpaid INV-890099-0002 Jan 20, 2023 Final Payment $4,274.78

   
 * question?
 * Authorize payment