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1 forms found in the DOM

POST ./charge.php

<form action="./charge.php" method="post" id="payment-form">
  <div style="max-width: 600px; margin: 0 auto;">
    <div class="section step active" data-step="1">
      <div class="section">
        <h1>Payment Method</h1>
      </div>
      <div class="payment-types-wrapper">
        <!-- Charge Information Section -->
        <div class="form-group form-group-payment-type">
          <p style="text-align: left;">Please select your payment type.</p>
          <br><br>
          <br>
          <br>
          <div class="payment-types-buttons">
            <div class="wrapper"><button type="button" class="payment-type-pay-now btn btn-primary">Pay Now</button></div>
            <div class="wrapper"><button type="button" class="payment-type-payment-on-file btn btn-primary">Payment on File</button></div>
          </div>
        </div>
        <div class="form-group form-group-payment-method" style="display: none;">
          <p style="text-align: left;">Please select your payment type.</p>
          <br>
          <br>
          <div class="payment-types-buttons">
            <div class="wrapper">
              <button type="button" class="payment-type-credit-card btn btn-primary">Credit Card</button>
              <div class="credit-card-pay-now-notes payment-notes"> Make an immediate payment using a credit card. Limit: Up to $5,000.<br>
                <em>Note: For amounts over $5,000, use the ACH/Bank Transfer option.</em>
              </div>
              <div class="credit-card-pay-on-file-notes payment-notes"> Credit card payments will be automatically processed for any outstanding balance when due. Limit: Up to $5,000.<br>
                <em>Note: For amounts over $5,000, use the ACH/Bank Transfer option.</em>
              </div>
            </div>
            <div class="wrapper">
              <button type="button" class="payment-type-ach btn btn-primary">ACH/Bank</button>
              <div class="bank-pay-now-notes payment-notes"> Make an immediate payment via ACH transfer. Processing Time: ACH transactions may take up to 4 days to post to your account.<br>
                <em>Note: Declined ACH payments are subject to fees.</em>
              </div>
              <div class="bank-pay-on-file-notes payment-notes"> ACH payments will be automatically processed for any outstanding balance when due. Processing Time: ACH transactions may take up to 4 days to post to your account.<br>
                <em>Note: Declined ACH payments are subject to fees.</em>
              </div>
            </div>
          </div>
          <div class="actions">
            <button type="button" class="back-to-payment-type btn btn-secondary">Back</button>
          </div>
        </div>
        <div class="form-group form-group-payment-amount" style="display: none;">
          <br>
          <div class="form-group">
            <label for="name">Amount to pay</label>
            <input id="amount" name="amount" type="text">
            <span class="error-message"></span>
          </div>
          <br><br>
          <div class="actions">
            <button type="button" class="back-to-payment-method btn btn-secondary">Back</button>
            <button type="button" class="btn-next btn btn-primary">Next</button>
          </div>
        </div>
        <input type="hidden" value="" id="note" name="note">
      </div>
    </div>
    <div class="section step" data-step="2">
      <div class="section">
        <h1>Store Location</h1>
      </div>
      <span class="detail">(You must select a location and payment type in order to complete this form. If you would like multiple locations, please submit a form for each location)</span>
      <div class="form-group">
        <div class="form-group">
          <select required="required" class="form-control" type="radio" name="store" id="location">
            <option value="">Select Location</option>
            <option value="South Bend, IN">South Bend, IN</option>
          </select>
          <span class="error-message"></span>
        </div>
      </div>
      <div class="actions">
        <button type="button" class="btn-back btn btn-secondary">Back</button>
        <button type="button" class="btn-next btn btn-primary">Next</button>
      </div>
    </div>
    <div class="section step" data-step="3">
      <div class="section">
        <h1>Billing Authorization Form</h1>
      </div>
      <!--- Customer Information Section --->
      <div class="section">
        <div class="form-group">
          <label for="name">Customer Name</label>
          <input id="name" name="name" type="text" value="">
          <span class="error-message"></span>
        </div>
        <div class="form-group">
          <label for="address">Address</label>
          <input id="address" name="address" type="text" value="">
          <span class="error-message"></span>
        </div>
        <div class="form-group">
          <label for="city" class="inline">City</label>
          <input id="city" name="city" type="text" size="15" value="">
          <span class="error-message"></span>
        </div>
        <div class="form-group">
          <label for="state" class="inline">State/Province</label>
          <select id="state" name="state">
            <option value="">Select state</option>
            <optgroup label="United States">
              <option value="AL">Alabama</option>
              <option value="AK">Alaska</option>
              <option value="AS">American Samoa</option>
              <option value="AZ">Arizona</option>
              <option value="AR">Arkansas</option>
              <option value="CA">California</option>
              <option value="CO">Colorado</option>
              <option value="CT">Connecticut</option>
              <option value="DE">Delaware</option>
              <option value="DC">District Of Columbia</option>
              <option value="FM">Federated States Of Micronesia</option>
              <option value="FL">Florida</option>
              <option value="GA">Georgia</option>
              <option value="GU">Guam</option>
              <option value="HI">Hawaii</option>
              <option value="ID">Idaho</option>
              <option value="IL">Illinois</option>
              <option value="IN">Indiana</option>
              <option value="IA">Iowa</option>
              <option value="KS">Kansas</option>
              <option value="KY">Kentucky</option>
              <option value="LA">Louisiana</option>
              <option value="ME">Maine</option>
              <option value="MH">Marshall Islands</option>
              <option value="MD">Maryland</option>
              <option value="MA">Massachusetts</option>
              <option value="MI">Michigan</option>
              <option value="MN">Minnesota</option>
              <option value="MS">Mississippi</option>
              <option value="MO">Missouri</option>
              <option value="MT">Montana</option>
              <option value="NE">Nebraska</option>
              <option value="NV">Nevada</option>
              <option value="NH">New Hampshire</option>
              <option value="NJ">New Jersey</option>
              <option value="NM">New Mexico</option>
              <option value="NY">New York</option>
              <option value="NC">North Carolina</option>
              <option value="ND">North Dakota</option>
              <option value="MP">Northern Mariana Islands</option>
              <option value="OH">Ohio</option>
              <option value="OK">Oklahoma</option>
              <option value="OR">Oregon</option>
              <option value="PW">Palau</option>
              <option value="PA">Pennsylvania</option>
              <option value="PR">Puerto Rico</option>
              <option value="RI">Rhode Island</option>
              <option value="SC">South Carolina</option>
              <option value="SD">South Dakota</option>
              <option value="TN">Tennessee</option>
              <option value="TX">Texas</option>
              <option value="UT">Utah</option>
              <option value="VT">Vermont</option>
              <option value="VI">Virgin Islands</option>
              <option value="VA">Virginia</option>
              <option value="WA">Washington</option>
              <option value="WV">West Virginia</option>
              <option value="WI">Wisconsin</option>
              <option value="WY">Wyoming</option>
            </optgroup>
            <optgroup label="Canada">
              <option value="AB">Alberta</option>
              <option value="BC">British Columbia</option>
              <option value="MB">Manitoba</option>
              <option value="NB">New Brunswick</option>
              <option value="NL">Newfoundland &amp; Labrador</option>
              <option value="NT">Northwest Territories</option>
              <option value="NS">Nova Scotia</option>
              <option value="NU">Nuvanut</option>
              <option value="ON">Ontario</option>
              <option value="PE">Prince Edward Island</option>
              <option value="QC">Quebec</option>
              <option value="SK">Saskatchewan</option>
              <option value="YT">Yukon</option>
            </optgroup>
            <optgroup label="Other">
              <option value="NAA">Not Applicable</option>
            </optgroup>
          </select>
          <span class="error-message"></span>
        </div>
        <div class="form-group">
          <label for="country" class="inline">Country</label>
          <select id="country" name="country">
            <option>Select country</option>
            <option value="CA">Canada</option>
            <option value="US" selected="selected">United States</option>
          </select>
          <span class="error-message"></span>
        </div>
        <div class="form-group">
          <label for="zip" class="inline">Zip</label>
          <input id="zip" name="zip" size="10" maxlength="10" value="">
          <span class="error-message"></span>
        </div>
        <div class="form-group">
          <label for="phone">Phone</label>
          <input id="phone" name="phone" type="text" value="">
          <span class="error-message"></span>
        </div>
        <div class="form-group">
          <div class="note" style="margin: 1em 0; color:red; font-size: 1em;"> *Email on Account: To ensure your payment is applied correctly to your account, please use the email address you have on file with the Bayview, please email
            support@ibsinternet.com and a team member will assist you with verifying and/or changing your email on file* </div>
        </div>
        <div class="form-group">
          <label for="email">Email Address</label>
          <input id="email" name="email" type="text" value="">
          <span class="error-message"></span>
        </div>
      </div>
      <div class="actions">
        <button type="button" class="btn-back btn btn-secondary">Back</button>
        <button type="button" class="btn-next btn btn-primary">Next</button>
      </div>
    </div>
    <div class="section step" data-step="4">
      <!--- Card Information Section --->
      <div class="section">
        <div class="ach-embed-wrapper">
          <div id="ach-embed"></div>
        </div>
        <div class="amount-info"></div>
        <div class="creditcard-wrapper">
          <h2>Credit Card Information</h2>
          <div class="form-group">
            <label for="card-element">Credit Card Details</label>
            <div id="card-element">
              <!-- a Stripe Element will be inserted here. -->
            </div>
            <!-- Used to display form errors -->
            <div id="card-errors"></div>
          </div>
        </div>
      </div>
      <div class="section">
        <div class="footnote">**"By clicking 'Submit' on this form, you acknowledge and agree that you have read and consent to our <a target="_blank" href="Terms-and-Conditions.pdf">Terms and Conditions</a></div>
      </div>
      <div class="actions">
        <button type="button" class="btn-back btn btn-secondary">Back</button>
        <button type="button" class="btn-submit btn btn-primary">Submit</button>
      </div>
    </div>
  </div>
  <input type="hidden" id="paytype" name="paytype">
</form>

Text Content

555-123-1234

×


TERMS AND CONDITIONS FOR PAYMENT ON FILE

I hereby grant authorization to Bayview to issue instructions to the financial
institution that issued my card for the purpose of processing payments from my
card account or ACH account, in accordance with the terms outlined in our
agreement. I have enrolled in the Payment on File option, Bayview is authorized
to automatically process my credit card or ACH account for any outstanding
balances or at the point of sale.

ACH payments may take up to 4 days to post to your account. Declined payments
are subject to fees.

I Agree I do not agree
×


STRIPE TERMS AND CONDITIONS FOR ONE TIME PAYMENT

I hereby grant authorization to Bayviewto issue instructions to the financial
institution that issued my card for the purpose of processing payments from my
card account or ACH account, in accordance with the terms outlined in our
agreement. I have enrolled in the One-Time payment option, I confirm that I am
the initiating party and hereby authorize the payment. It is understood that
Bayview reserves the right to pass on any credit card dispute fees to me as the
customer.

ACH payments may take up to 4 days to post to your account. Declined payments
are subject to fees.

I Agree I do not agree
Step 1: Payment Method
Step 2: Store Location
Step 3: Customer Information
Step 4: Payment Details


PAYMENT METHOD

Please select your payment type.





Pay Now
Payment on File

Please select your payment type.



Credit Card
Make an immediate payment using a credit card. Limit: Up to $5,000.
Note: For amounts over $5,000, use the ACH/Bank Transfer option.
Credit card payments will be automatically processed for any outstanding balance
when due. Limit: Up to $5,000.
Note: For amounts over $5,000, use the ACH/Bank Transfer option.
ACH/Bank
Make an immediate payment via ACH transfer. Processing Time: ACH transactions
may take up to 4 days to post to your account.
Note: Declined ACH payments are subject to fees.
ACH payments will be automatically processed for any outstanding balance when
due. Processing Time: ACH transactions may take up to 4 days to post to your
account.
Note: Declined ACH payments are subject to fees.
Back


Amount to pay


Back Next


STORE LOCATION

(You must select a location and payment type in order to complete this form. If
you would like multiple locations, please submit a form for each location)
Select Location South Bend, IN
Back Next


BILLING AUTHORIZATION FORM

Customer Name
Address
City
State/Province Select state Alabama Alaska American Samoa Arizona Arkansas
California Colorado Connecticut Delaware District Of Columbia Federated States
Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas
Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan
Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey
New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio
Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South
Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West
Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick
Newfoundland & Labrador Northwest Territories Nova Scotia Nuvanut Ontario Prince
Edward Island Quebec Saskatchewan Yukon Not Applicable
Country Select country Canada United States
Zip
Phone
*Email on Account: To ensure your payment is applied correctly to your account,
please use the email address you have on file with the Bayview, please email
support@ibsinternet.com and a team member will assist you with verifying and/or
changing your email on file*
Email Address
Back Next


CREDIT CARD INFORMATION

Credit Card Details


**"By clicking 'Submit' on this form, you acknowledge and agree that you have
read and consent to our Terms and Conditions
Back Submit

FOR HELP MAKING A PAYMENT: 555-123-1234 Bayview, 300 W Jefferson Blvd. South
Bend, Indiana 46601

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