web.na.bambora.com
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204.101.59.116
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Submitted URL: https://preauth.baytek.ca/
Effective URL: https://web.na.bambora.com/scripts/payment/payment.asp?merchant_id=117589105&hashValue=8ec1be81b0c7d70d6d53fe23bc777a384dba...
Submission: On September 16 via automatic, source certstream-suspicious — Scanned from DE
Effective URL: https://web.na.bambora.com/scripts/payment/payment.asp?merchant_id=117589105&hashValue=8ec1be81b0c7d70d6d53fe23bc777a384dba...
Submission: On September 16 via automatic, source certstream-suspicious — Scanned from DE
Form analysis 1 forms found in the DOM
POST /scripts/payment/payment.asp
<form action="/scripts/payment/payment.asp" method="post" id="frmPayment">
<input type="hidden" id="sessionToken" name="sessionToken" value="E5D675B3-2C04-4D7D-93C309DE30FF9">
<input type="hidden" id="paymentAction" name="paymentAction" value="">
<input type="hidden" id="merchant_id" name="merchant_id" value="117589105">
<input type="hidden" id="preview" name="preview" value="">
<input type="hidden" id="visaCheckoutCallId" name="visaCheckoutCallId" value="">
<input type="hidden" id="aDFinancingType" name="aDFinancingType" value="">
<input type="hidden" id="aDPlanNumber" name="aDPlanNumber" value="">
<input type="hidden" id="aDGracePeriod" name="aDGracePeriod" value="">
<input type="hidden" id="aDTerm" name="aDTerm" value="">
<table id="apple_pay_button" border="0" cellpadding="0" cellspacing="1" style="width:100%;display:none">
<tbody>
<tr>
<td colspan="3" height="30px" valign="top" align="right">
<div class="apple-pay-button apple-pay-button-black" onclick="applePayButtonClicked()"></div>
</td>
</tr>
</tbody>
</table>
<table border="0" cellpadding="0" cellspacing="1">
<tbody>
<tr>
<td colspan="3" height="30px" valign="top" align="right">
<font face="Arial" size="2" color="000000">
<br>
<table width="100%">
<tbody>
<tr>
<td style="width:154px">
<div name="divVCButton" id="divVCButton" style="height: 36px; vertical-align:top"><img name="vcButton" id="vcButton" class="v-button" role="button" height="34px" alt="Click to pay with payment icon"
src="https://secure.checkout.visa.com/wallet-services-web/xo/button.png?animation=true&legacy=false&svg=true&orderedCardBrands=VISA%2CAMEX" tabindex="0" title="Click to pay with payment icon"
style="cursor: pointer;"></div>
<div style="width:154px; text-align:right !important"><a class="v-learn" href="#" data-locale="en_CA" aria-label="Learn more about Visa Checkout">Tell Me More</a></div>
</td>
</tr>
</tbody>
</table>
<br>
</font>
</td>
</tr>
<tr>
<td colspan="3" height="30px" valign="top">
<font face="Arial" size="3" color="000000"><b>Billing Information</b></font>
</td>
</tr>
<tr>
<td rowspan="9"> </td>
<td>
<font face="Arial" size="2" color="000000">Name:</font>
</td>
<td><input type="text" name="ordName" value="" size="30" maxlength="64" autocomplete="off"></td>
</tr>
<tr>
<td>
<font face="Arial" size="2" color="000000">Phone Number:</font>
</td>
<td><input type="text" name="ordPhoneNumber" value="" size="30" maxlength="32" autocomplete="off"></td>
</tr>
<tr>
<td>
<font face="Arial" size="2" color="000000">Address Line 1:</font>
</td>
<td><input type="text" name="ordAddress1" value="" size="30" maxlength="64" autocomplete="off"></td>
</tr>
<tr>
<td>
<font face="Arial" size="2" color="000000">Address Line 2:</font>
</td>
<td><input type="text" name="ordAddress2" value="" size="30" maxlength="64" autocomplete="off"></td>
</tr>
<tr>
<td>
<font face="Arial" size="2" color="000000"><span id="ordCountry_cityLabel">City</span>:</font>
</td>
<td><input type="text" name="ordCity" value="" size="30" maxlength="32" autocomplete="off"></td>
</tr>
<tr id="ordCountry_displayProvince">
<td>
<font face="Arial" size="2" color="000000"><span id="ordCountry_provinceLabel">Province</span>:</font>
</td>
<td>
<select name="ordProvince" id="ordProvince" style="width:203" width="203">
<option value="" disabled="">Select your state/province: </option>
<option value="--" disabled="" style="display: none;">Outside U.S./Canada</option>
<optgroup id="ordProvince_country_CA" 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 and Labrador</option>
<option value="NT">Northwest Territories</option>
<option value="NS">Nova Scotia</option>
<option value="NU">Nunavut</option>
<option value="ON" selected="selected">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 id="ordProvince_country_US" label="United States" disabled="" style="display: none;">
<option value="AL" disabled="" style="display: none;">Alabama</option>
<option value="AK" disabled="" style="display: none;">Alaska</option>
<option value="AS" disabled="" style="display: none;">American Samoa</option>
<option value="AZ" disabled="" style="display: none;">Arizona</option>
<option value="AR" disabled="" style="display: none;">Arkansas</option>
<option value="AA" disabled="" style="display: none;">Armed Forces Americas</option>
<option value="AE" disabled="" style="display: none;">Armed Forces Europe</option>
<option value="AP" disabled="" style="display: none;">Armed Forces Pacific</option>
<option value="CA" disabled="" style="display: none;">California</option>
<option value="CO" disabled="" style="display: none;">Colorado</option>
<option value="CT" disabled="" style="display: none;">Connecticut</option>
<option value="DE" disabled="" style="display: none;">Delaware</option>
<option value="DC" disabled="" style="display: none;">District of Columbia</option>
<option value="FL" disabled="" style="display: none;">Florida</option>
<option value="GA" disabled="" style="display: none;">Georgia</option>
<option value="GU" disabled="" style="display: none;">Guam</option>
<option value="HI" disabled="" style="display: none;">Hawaii</option>
<option value="ID" disabled="" style="display: none;">Idaho</option>
<option value="IL" disabled="" style="display: none;">Illinois</option>
<option value="IN" disabled="" style="display: none;">Indiana</option>
<option value="IA" disabled="" style="display: none;">Iowa</option>
<option value="KS" disabled="" style="display: none;">Kansas</option>
<option value="KY" disabled="" style="display: none;">Kentucky</option>
<option value="LA" disabled="" style="display: none;">Louisiana</option>
<option value="ME" disabled="" style="display: none;">Maine</option>
<option value="MD" disabled="" style="display: none;">Maryland</option>
<option value="MA" disabled="" style="display: none;">Massachusetts</option>
<option value="MI" disabled="" style="display: none;">Michigan</option>
<option value="MN" disabled="" style="display: none;">Minnesota</option>
<option value="MS" disabled="" style="display: none;">Mississippi</option>
<option value="MO" disabled="" style="display: none;">Missouri</option>
<option value="MT" disabled="" style="display: none;">Montana</option>
<option value="NE" disabled="" style="display: none;">Nebraska</option>
<option value="NV" disabled="" style="display: none;">Nevada</option>
<option value="NH" disabled="" style="display: none;">New Hampshire</option>
<option value="NJ" disabled="" style="display: none;">New Jersey</option>
<option value="NM" disabled="" style="display: none;">New Mexico</option>
<option value="NY" disabled="" style="display: none;">New York</option>
<option value="NC" disabled="" style="display: none;">North Carolina</option>
<option value="ND" disabled="" style="display: none;">North Dakota</option>
<option value="MP" disabled="" style="display: none;">Northern Marianas</option>
<option value="OH" disabled="" style="display: none;">Ohio</option>
<option value="OK" disabled="" style="display: none;">Oklahoma</option>
<option value="OR" disabled="" style="display: none;">Oregon</option>
<option value="PW" disabled="" style="display: none;">Palau</option>
<option value="PA" disabled="" style="display: none;">Pennsylvania</option>
<option value="PR" disabled="" style="display: none;">Puerto Rico</option>
<option value="RI" disabled="" style="display: none;">Rhode Island</option>
<option value="SC" disabled="" style="display: none;">South Carolina</option>
<option value="SD" disabled="" style="display: none;">South Dakota</option>
<option value="TN" disabled="" style="display: none;">Tennessee</option>
<option value="TX" disabled="" style="display: none;">Texas</option>
<option value="UT" disabled="" style="display: none;">Utah</option>
<option value="VT" disabled="" style="display: none;">Vermont</option>
<option value="VI" disabled="" style="display: none;">Virgin Islands</option>
<option value="VA" disabled="" style="display: none;">Virginia</option>
<option value="WA" disabled="" style="display: none;">Washington</option>
<option value="WV" disabled="" style="display: none;">West Virginia</option>
<option value="WI" disabled="" style="display: none;">Wisconsin</option>
<option value="WY" disabled="" style="display: none;">Wyoming</option>
</optgroup>
</select>
</td>
</tr>
<tr>
<td>
<font face="Arial" size="2" color="000000"><span id="ordCountry_postalLabel">Postal Code</span>:</font>
</td>
<td><input type="text" name="ordPostalCode" value="" size="30" maxlength="32" autocomplete="off"> </td>
</tr>
<tr>
<td>
<font face="Arial" size="2" color="000000">Country:</font>
</td>
<td>
<select id="ordCountry" name="ordCountry" style="width:203" onchange="CountryUpdate(this, document.getElementById('frmPayment').ordProvince);">
<option value="AF"> Afghanistan </option>
<option value="AX"> Åland Islands </option>
<option value="AL"> Albania </option>
<option value="DZ"> Algeria </option>
<option value="AS"> American Samoa </option>
<option value="AD"> Andorra </option>
<option value="AO"> Angola </option>
<option value="AI"> Anguilla </option>
<option value="AQ"> Antarctica </option>
<option value="AG"> Antigua and Barbuda </option>
<option value="AR"> Argentina </option>
<option value="AM"> Armenia </option>
<option value="AW"> Aruba </option>
<option value="AU"> Australia </option>
<option value="AT"> Austria </option>
<option value="AZ"> Azerbaijan </option>
<option value="BS"> Bahamas </option>
<option value="BH"> Bahrain </option>
<option value="BD"> Bangladesh </option>
<option value="BB"> Barbados </option>
<option value="BY"> Belarus </option>
<option value="BE"> Belgium </option>
<option value="BZ"> Belize </option>
<option value="BJ"> Benin </option>
<option value="BM"> Bermuda </option>
<option value="BT"> Bhutan </option>
<option value="BO"> Bolivia </option>
<option value="BA"> Bosnia and Herzegovina </option>
<option value="BW"> Botswana </option>
<option value="BV"> Bouvet Island </option>
<option value="BR"> Brazil </option>
<option value="IO"> British Indian Ocean Territory </option>
<option value="BN"> Brunei Darussalam </option>
<option value="BG"> Bulgaria </option>
<option value="BF"> Burkina Faso </option>
<option value="BI"> Burundi </option>
<option value="KH"> Cambodia </option>
<option value="CM"> Cameroon </option>
<option value="CA" selected=""> Canada </option>
<option value="CV"> Cape Verde </option>
<option value="KY"> Cayman Islands </option>
<option value="CF"> Central African Republic </option>
<option value="TD"> Chad </option>
<option value="CL"> Chile </option>
<option value="CN"> China </option>
<option value="CX"> Christmas Island </option>
<option value="CC"> Cocos (Keeling) Islands </option>
<option value="CO"> Colombia </option>
<option value="KM"> Comoros </option>
<option value="CG"> Congo </option>
<option value="CD"> Congo, The Democratic Republic of the </option>
<option value="CK"> Cook Islands </option>
<option value="CR"> Costa Rica </option>
<option value="CI"> Côte D’ivoire </option>
<option value="HR"> Croatia </option>
<option value="CU"> Cuba </option>
<option value="CY"> Cyprus </option>
<option value="CZ"> Czech Republic </option>
<option value="DK"> Denmark </option>
<option value="DJ"> Djibouti </option>
<option value="DM"> Dominica </option>
<option value="DO"> Dominican Republic </option>
<option value="EC"> Ecuador </option>
<option value="EG"> Egypt </option>
<option value="SV"> El Salvador </option>
<option value="GQ"> Equatorial Guinea </option>
<option value="ER"> Eritrea </option>
<option value="EE"> Estonia </option>
<option value="ET"> Ethiopia </option>
<option value="FK"> Falkland Islands (Malvinas) </option>
<option value="FO"> Faroe Islands </option>
<option value="FJ"> Fiji </option>
<option value="FI"> Finland </option>
<option value="FR"> France </option>
<option value="GF"> French Guiana </option>
<option value="PF"> French Polynesia </option>
<option value="TF"> French Southern Territories </option>
<option value="GA"> Gabon </option>
<option value="GM"> Gambia </option>
<option value="GE"> Georgia </option>
<option value="DE"> Germany </option>
<option value="GH"> Ghana </option>
<option value="GI"> Gibraltar </option>
<option value="GR"> Greece </option>
<option value="GL"> Greenland </option>
<option value="GD"> Grenada </option>
<option value="GP"> Guadeloupe </option>
<option value="GU"> Guam </option>
<option value="GT"> Guatemala </option>
<option value="GG"> Guernsey </option>
<option value="GN"> Guinea </option>
<option value="GW"> Guinea-Bissau </option>
<option value="GY"> Guyana </option>
<option value="HT"> Haiti </option>
<option value="HM"> Heard Island and McDonald Islands </option>
<option value="VA"> Holy See (Vatican City state) </option>
<option value="HN"> Honduras </option>
<option value="HK"> Hong Kong </option>
<option value="HU"> Hungary </option>
<option value="IS"> Iceland </option>
<option value="IN"> India </option>
<option value="ID"> Indonesia </option>
<option value="IR"> Iran, Islamic Republic of </option>
<option value="IQ"> Iraq </option>
<option value="IE"> Ireland </option>
<option value="IM"> Isle Of Man </option>
<option value="IL"> Israel </option>
<option value="IT"> Italy </option>
<option value="JM"> Jamaica </option>
<option value="JP"> Japan </option>
<option value="JE"> Jersey </option>
<option value="JO"> Jordan </option>
<option value="KZ"> Kazakhstan </option>
<option value="KE"> Kenya </option>
<option value="KI"> Kiribati </option>
<option value="KP"> Korea, Democratic People’s Republic Of </option>
<option value="KR"> Korea, Republic of </option>
<option value="KW"> Kuwait </option>
<option value="KG"> Kyrgyzstan </option>
<option value="LA"> Lao People’s Democratic Republic </option>
<option value="LV"> Latvia </option>
<option value="LB"> Lebanon </option>
<option value="LS"> Lesotho </option>
<option value="LR"> Liberia </option>
<option value="LY"> Libyan Arab Jamahiriya </option>
<option value="LI"> Liechtenstein </option>
<option value="LT"> Lithuania </option>
<option value="LU"> Luxembourg </option>
<option value="MO"> Macao </option>
<option value="MK"> Macedonia, The Former Yugoslav Republic of </option>
<option value="MG"> Madagascar </option>
<option value="MW"> Malawi </option>
<option value="MY"> Malaysia </option>
<option value="MV"> Maldives </option>
<option value="ML"> Mali </option>
<option value="MT"> Malta </option>
<option value="MH"> Marshall Islands </option>
<option value="MQ"> Martinique </option>
<option value="MR"> Mauritania </option>
<option value="MU"> Mauritius </option>
<option value="YT"> Mayotte </option>
<option value="MX"> Mexico </option>
<option value="FM"> Micronesia, Federated States of </option>
<option value="MD"> Moldova, Republic of </option>
<option value="MC"> Monaco </option>
<option value="MN"> Mongolia </option>
<option value="ME"> Montenegro </option>
<option value="MS"> Montserrat </option>
<option value="MA"> Morocco </option>
<option value="MZ"> Mozambique </option>
<option value="MM"> Myanmar </option>
<option value="NA"> Namibia </option>
<option value="NR"> Nauru </option>
<option value="NP"> Nepal </option>
<option value="NL"> Netherlands </option>
<option value="AN"> Netherlands Antilles </option>
<option value="NC"> New Caledonia </option>
<option value="NZ"> New Zealand </option>
<option value="NI"> Nicaragua </option>
<option value="NE"> Niger </option>
<option value="NG"> Nigeria </option>
<option value="NU"> Niue </option>
<option value="NF"> Norfolk Island </option>
<option value="MP"> Northern Mariana Islands </option>
<option value="NO"> Norway </option>
<option value="OM"> Oman </option>
<option value="PK"> Pakistan </option>
<option value="PW"> Palau </option>
<option value="PS"> Palestinian Territory, Occupied </option>
<option value="PA"> Panama </option>
<option value="PG"> Papua New Guinea </option>
<option value="PY"> Paraguay </option>
<option value="PE"> Peru </option>
<option value="PH"> Philippines </option>
<option value="PN"> Pitcairn </option>
<option value="PL"> Poland </option>
<option value="PT"> Portugal </option>
<option value="PR"> Puerto Rico </option>
<option value="QA"> Qatar </option>
<option value="RE"> Reunion </option>
<option value="RO"> Romania </option>
<option value="RU"> Russian Federation </option>
<option value="RW"> Rwanda </option>
<option value="BL"> Saint Barthélemy </option>
<option value="SH"> Saint Helena </option>
<option value="KN"> Saint Kitts and Nevis </option>
<option value="LC"> Saint Lucia </option>
<option value="MF"> Saint Martin </option>
<option value="PM"> Saint Pierre and Miquelon </option>
<option value="VC"> Saint Vincent and the Grenadines </option>
<option value="WS"> Samoa </option>
<option value="SM"> San Marino </option>
<option value="ST"> Sao Tome and Principe </option>
<option value="SA"> Saudi Arabia </option>
<option value="SN"> Senegal </option>
<option value="RS"> Serbia </option>
<option value="CS"> Serbia and Montenegro </option>
<option value="SC"> Seychelles </option>
<option value="SL"> Sierra Leone </option>
<option value="SG"> Singapore </option>
<option value="SK"> Slovakia </option>
<option value="SI"> Slovenia </option>
<option value="SB"> Solomon Islands </option>
<option value="SO"> Somalia </option>
<option value="ZA"> South Africa </option>
<option value="GS"> South Georgia and the South Sandwich Islands </option>
<option value="ES"> Spain </option>
<option value="LK"> Sri Lanka </option>
<option value="SD"> Sudan </option>
<option value="SR"> Suriname </option>
<option value="SJ"> Svalbard and Jan Mayen </option>
<option value="SZ"> Swaziland </option>
<option value="SE"> Sweden </option>
<option value="CH"> Switzerland </option>
<option value="SY"> Syrian Arab Republic </option>
<option value="TW"> Taiwan </option>
<option value="TJ"> Tajikistan </option>
<option value="TZ"> Tanzania, United Republic of </option>
<option value="TH"> Thailand </option>
<option value="TL"> Timor-Leste </option>
<option value="TG"> Togo </option>
<option value="TK"> Tokelau </option>
<option value="TO"> Tonga </option>
<option value="TT"> Trinidad and Tobago </option>
<option value="TN"> Tunisia </option>
<option value="TR"> Turkey </option>
<option value="TM"> Turkmenistan </option>
<option value="TC"> Turks and Caicos Islands </option>
<option value="TV"> Tuvalu </option>
<option value="UG"> Uganda </option>
<option value="UA"> Ukraine </option>
<option value="AE"> United Arab Emirates </option>
<option value="GB"> United Kingdom </option>
<option value="US"> United States </option>
<option value="UM"> United States Minor Outlying Islands </option>
<option value="UY"> Uruguay </option>
<option value="UZ"> Uzbekistan </option>
<option value="VU"> Vanuatu </option>
<option value="VE"> Venezuela </option>
<option value="VN"> Viet Nam </option>
<option value="VG"> Virgin Islands, British </option>
<option value="VI"> Virgin Islands, U.S. </option>
<option value="WF"> Wallis and Futuna </option>
<option value="EH"> Western Sahara </option>
<option value="YE"> Yemen </option>
<option value="ZM"> Zambia </option>
<option value="ZW"> Zimbabwe </option>
</select>
</td>
</tr>
<tr>
<td>
<font face="Arial" size="2" color="000000">Email:</font>
</td>
<td><input type="text" name="ordEmailAddress" value="" size="30" maxlength="64" autocomplete="off"></td>
</tr>
<tr>
<td colspan="3" height="0"><input type="hidden" name="shipName" value=""><input type="hidden" name="shipEmailAddress" value=""><input type="hidden" name="shipPhoneNumber" value=""><input type="hidden" name="shipAddress1" value=""><input
type="hidden" name="shipAddress2" value=""><input type="hidden" name="shipCity" value=""><input type="hidden" name="shipProvince" value=""><input type="hidden" name="shipPostalCode" value=""><input type="hidden" name="shipCountry"
value=""></td>
</tr>
<tr>
<td colspan="3"><br></td>
</tr>
<tr>
<td colspan="3" height="45px" valign="top">
<div style="float:left;">
<font face="Arial" size="3" color="000000"><b>Payment Information</b></font>
</div>
</td>
</tr>
<tr>
<td colspan="3" valign="top" align="right"> <img style="margin-left: 10px; display:inline-block;" src="/shared_resources/cardLogos/20_PV_cardLogo.png">
<img style="margin-left: 10px; display:inline-block;" src="/shared_resources/cardLogos/35_MD_cardLogo.png">
<img style="margin-left: 10px; display:inline-block;" src="/shared_resources/cardLogos/40_NN_cardLogo.jpg">
<img style="margin-left: 10px; display:inline-block;" src="/shared_resources/cardLogos/50_AM_cardLogo.png">
</td>
</tr>
<tr>
<td rowspan="7"> </td>
<td>
<font face="Arial" size="2" color="000000">Invoice/Order Number:</font>
</td>
<td><input type="text" name="trnOrderNumber" value="" size="30" maxlength="30" autocomplete="off"></td>
</tr>
<tr>
<td>
<font face="Arial" size="2" color="000000">Amount (CAD):</font>
</td>
<td><input type="text" name="trnAmount" value="5" size="30" maxlength="32" onblur="if (PositiveInteger(this) == true) {FormatAmount(this);}" autocomplete="off"></td>
</tr>
<input type="hidden" name="paymentMethod" value="CC">
<tr>
<td>
<font face="Arial" size="2" color="000000">Name on card:</font>
</td>
<td><input type="text" name="trnCardOwner" value="" size="30" maxlength="64" autocomplete="off"></td>
</tr>
<tr>
<td>
<font face="Arial" size="2" color="000000">Card Type:</font>
</td>
<td>
<select name="trnCardType" onchange="CheckPaymentType()">
<option value="VI">VISA</option>
<option value="PV">VISA Debit</option>
<option value="MC">MasterCard</option>
<option value="MD">Debit MasterCard</option>
<option value="AM">AMEX</option>
<option value="NN">Discover</option>
</select>
</td>
</tr>
<tr>
<td>
<font face="Arial" size="2" color="000000">Card Number:</font>
</td>
<td><input type="text" name="trnCardNumber" value="" size="30" maxlength="20" onchange="ValidateCardNumber();" autocomplete="off"></td>
</tr>
<tr>
<td>
<font face="Arial" size="2" color="000000">Expiration Date:</font>
</td>
<td>
<select name="trnExpMonth">
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select> / <select name="trnExpYear">
<option value="21">2021</option>
<option value="22">2022</option>
<option value="23">2023</option>
<option value="24">2024</option>
<option value="25">2025</option>
<option value="26">2026</option>
<option value="27">2027</option>
<option value="28">2028</option>
<option value="29">2029</option>
<option value="30">2030</option>
<option value="31">2031</option>
<option value="32">2032</option>
<option value="33">2033</option>
</select>
</td>
</tr>
<tr>
<td>
<font face="Arial" size="2" color="000000">Card CVD:</font>
</td>
<td style="font-family: arial, helvetica; font-size: 8pt;">
<input type="text" name="trnCardCvd" value="" size="4" maxlength="4" onchange="ValidateCvdField(this, false);" autocomplete="off"> <a href="JavaScript:openCvdHelp();">What's this?</a>
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<td><input type="button" name="submitButton" value="Pre-Authorize my Credit Card" onclick="SubmitTrans();"></td>
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</form>Text Content
Please complete the form below to pre-authorize your credit card: City Province Postal Code True City State Zip True Town/City Postcode False City Province/State Postal/Zip False City Province/State Postal/Zip False Tell Me More Billing Information Name: Phone Number: Address Line 1: Address Line 2: City: Province: Select your state/province: Outside U.S./Canada Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas 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 Postal Code: Country: Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic of the Cook Islands Costa Rica Côte D’ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City state) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle Of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People’s Republic Of Korea, Republic of Kuwait Kyrgyzstan Lao People’s Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia, The Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Email: Payment Information Invoice/Order Number: Amount (CAD): Name on card: Card Type: VISA VISA Debit MasterCard Debit MasterCard AMEX Discover Card Number: Expiration Date: 01 02 03 04 05 06 07 08 09 10 11 12 / 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 Card CVD: What's this?