la-z-boy.delivery Open in urlscan Pro
216.151.16.229  Public Scan

Form analysis
2 forms found in the DOM

Name: ctl01 — POST ./

<form name="ctl01" method="post" action="./" id="ctl01">
  <div>
    <input type="hidden" name="__VIEWSTATE" id="__VIEWSTATE" value="8k5lA3GgLLe+5F+mjtD7RwtPWM4ouLizfoMxcd03ZVZ9hGDx+VGIsRGKSIo4Ej71yEU31xHOyVJZffTZTI3yv6vXLNHUZHbiT3n9W9vZ1AC3eAVj3yyPEg+oAdcUGmKPkXzVCmflWlwN3qlRpDfooQ==">
  </div>
  <div>
    <input type="hidden" name="__VIEWSTATEGENERATOR" id="__VIEWSTATEGENERATOR" value="CA0B0334">
    <input type="hidden" name="__EVENTVALIDATION" id="__EVENTVALIDATION" value="Dcut+nNYqv/Rb/1Dxm9ygM1REzi6+E519o1f6UxAkwj5hpmP4Lu0qo+jdrTkFWQCWnHLE16reXpF/gjnn6UYSpnIkskoyXKiJSot7mMdmoSAoQflJyQj5s6ivenVFKxw">
  </div>
  <input name="DateConfirmFooter" type="hidden" id="DateConfirmFooter">
  <br>
  <div id="NoStorePanel" class="error"> Please call the store and get a proper link to use this application. </div>
</form>

<form id="paymentForm">
  <h4 style="margin-top: 10px;">Billing Address</h4>
  <div class="form-row" style="display: none;">
    <div class="form-group col">
      <label for="companyName">Company</label>
      <input id="companyName" type="text" class="form-control">
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col">
      <label for="billingFirstName">First Name</label>
      <input id="billingFirstName" type="text" class="form-control" required="">
    </div>
    <div class="form-group col">
      <label for="billingLastName">Last Name</label>
      <input id="billingLastName" type="text" class="form-control" required="">
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col">
      <label for="billingAddress">Address</label>
      <input id="billingAddress" type="text" class="form-control" required="">
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col-md-6">
      <label for="billingCity">City</label>
      <input id="billingCity" type="text" class="form-control" required="">
    </div>
    <div class="form-group col-md-4">
      <label for="billingState">State/Province</label>
      <input id="billingState" type="text" class="form-control" maxlength="2" required="">
    </div>
    <div class="form-group col-md-2">
      <label for="billingZip">Zip/Postal Code</label>
      <input id="billingZip" type="text" class="form-control" maxlength="7" required="">
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col">
      <label for="billingEmail">Email</label>
      <input id="billingEmail" type="text" class="form-control">
    </div>
  </div>
  <h4 style="margin-top: 10px;">Payment</h4>
  <div id="paymentType" class="form-row" style="display: none;">
    <div class="form-check form-check-inline">
      <input class="form-check-input" type="radio" id="creditCardPaymentType" value="Credit Card">
      <label class="form-check-label" for="creditCardPaymentType">Credit Card</label>
    </div>
    <div class="form-check form-check-inline">
      <input class="form-check-input" type="radio" id="achPaymentType" value="ACH">
      <label class="form-check-label" for="achPaymentType">Bank Account</label>
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col">
      <label for="creditCardNumber">Card Number</label>
      <input id="creditCardNumber" type="text" class="form-control" maxlength="16" required="">
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col-auto">
      <label for="creditCardMonth">Month</label>
      <select id="creditCardMonth" class="form-control">
        <option value="1">1 - January</option>
        <option value="2">2 - February</option>
        <option value="3">3 - March</option>
        <option value="4">4 - April</option>
        <option value="5">5 - May</option>
        <option value="6">6 - June</option>
        <option value="7">7 - July</option>
        <option value="8">8 - August</option>
        <option value="9">9 - September</option>
        <option value="10">10 - October</option>
        <option value="11">11 - November</option>
        <option value="12">12 - December</option>
      </select>
    </div>
    <div class="form-group col-auto">
      <label for="creditCardYear">Year</label>
      <select id="creditCardYear" class="form-control"></select>
    </div>
    <div class="form-group col-auto">
      <label for="creditCardCode">Security Code</label>
      <input id="creditCardCode" type="text" class="form-control" maxlength="4" required="" minlength="3">
    </div>
  </div>
  <div id="achInfo" style="width: 465px; display: none;">
    <div class="clearit">
      <table>
        <tbody>
          <tr>
            <td>We accept echecks by using your banking information.</td>
          </tr>
        </tbody>
      </table>
    </div>
    <div class="lineheading emphit">Please enter your banking information below:</div>
    <div class="clearit"></div>
    <div>
      <table style="width: 400px;">
        <tbody>
          <tr>
            <td class="boldit">Account Type:</td>
            <td class="payType">
              <span class="boldit">Checking<input id="radioChecking" class="radio" type="radio" name="acctType" value="Checking"></span>
            </td>
            <td class="payType">
              <span class="boldit">Business Checking<input id="radioBusChecking" class="radio" type="radio" name="acctType"></span>
            </td>
            <td class="payType">&nbsp;<span class="boldit">Savings<input id="radioSavings" class="radio" type="radio" name="acctType"></span></td>
          </tr>
        </tbody>
      </table>
    </div>
    <div class="oneup">
      <label for="bankName">Bank Name</label><input type="text" id="bankName" title="Bank Name" maxlength="25">
    </div>
    <div class="clearit"></div>
    <div id="divCheckImage" style="display: none; background-color: Yellow; left: -20px; border: 1px solid black;"> You may find your bank routing number and checking account at the bottom of one of your checks. Please see the image below as an
      example:<br>
      <img src="images/CheckImageCut.png" alt="Check image showing bank routing and checking account number." title="Check Image">
    </div>
    <div class="oneup">
      <label for="bankRoutingNumber">Routing Number <span onmouseover="divCheckImage.style.display = 'block';" onmouseout="divCheckImage.style.display = 'none';">(?)</span>:</label><input type="text" id="bankRoutingNumber"
        title="Bank Routing Number">
    </div>
    <div class="clearit"></div>
    <div class="oneup">
      <label for="bankAccountNumber">Account Number <span onmouseover="divCheckImage.style.display = 'block';" onmouseout="divCheckImage.style.display = 'none';">(?)</span>:</label><input type="text" id="bankAccountNumber"
        title="Bank Account Number">
    </div>
    <div class="clearit"></div>
    <div class="oneup">
      <label for="bankAccountName">Name on Account:</label><input type="text" id="bankNameOnAccount" title="Name as it appears on bank account">
    </div>
    <div class="clearit"></div>
  </div>
  <div class="form-row">
    <div class="form-group col">
      <label for="paymentAmount">Amount</label>
      <input id="paymentAmount" type="text" class="form-control" readonly="">
    </div>
  </div>
  <div id="authorization">
    <p> By clicking the submit button below I authorize the credit card transaction indicated on this form, for a one time charge of <span id="authAmt"></span> on <span id="authDate"></span>. This payment is for goods and/or services detailed in the
      original receipt I received at the time I made my in store purchase. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company so long as the transaction corresponds to the
      terms indicated in this web form. </p>
    <p> I understand that returns, refunds, cancellations, deliveries, and privacy are covered by the <a id="authPolicy" href="#" target="_blank">terms and conditions agreement.</a>
    </p>
  </div>
  <div>
    <input type="button" id="paymentButton" class="btn-primary" onclick="processPayment();" value="Pay">
    <input type="button" id="paymentCancel" class="btn-secondary" onclick="reloadPage();" value="Cancel">
  </div>
</form>

Text Content

Please call the store and get a proper link to use this application.
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Privacy Policy
  Close
Order Number:
Balance:

BILLING ADDRESS

Company
First Name
Last Name
Address
City
State/Province
Zip/Postal Code
Email

PAYMENT

Credit Card
Bank Account
Card Number
Month 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 -
August 9 - September 10 - October 11 - November 12 - December
Year
Security Code

We accept echecks by using your banking information.

Please enter your banking information below:


Account Type: Checking Business Checking  Savings

Bank Name

You may find your bank routing number and checking account at the bottom of one
of your checks. Please see the image below as an example:

Routing Number (?):

Account Number (?):

Name on Account:

Amount

By clicking the submit button below I authorize the credit card transaction
indicated on this form, for a one time charge of on . This payment is for goods
and/or services detailed in the original receipt I received at the time I made
my in store purchase. I certify that I am an authorized user of this credit card
and that I will not dispute the payment with my credit card company so long as
the transaction corresponds to the terms indicated in this web form.

I understand that returns, refunds, cancellations, deliveries, and privacy are
covered by the terms and conditions agreement.










Payment Successful Close

Thank you for your payment. You will receive a confirmation email shortly.

Please click on the calendar icon to schedule your appointment.










Schedule Date Close









Appointment Scheduled Close
Great! We'll see you on .