curepaynow.com Open in urlscan Pro
190.92.149.13  Public Scan

Form analysis
1 forms found in the DOM

POST dmxConnect/api/merchant_cureclicks/process_submission.php

<form action="dmxConnect/api/merchant_cureclicks/process_submission.php" is="dmx-serverconnect-form" method="post" id="form_cureclick" novalidate="">
  <div class="row mt-4">
    <div class="col text-center">
      <p id="required_field_para1"><b>* - Indicates required fields.</b></p>
    </div>
  </div>
  <div class="modal" id="modal_payment_successful" is="dmx-bs5-modal" tabindex="-1">
    <div class="modal-dialog" role="document">
      <div class="modal-content">
        <div class="modal-header">
          <h5 class="modal-title text-success fw-bolder">Payment Successful</h5>
          <!-- <button type="button" class="btn-close" data-bs-dismiss="modal" aria-label="Close"></button> -->
        </div>
        <div class="modal-body">
          <p id="paragraph_thank_you_message" class="text-center fw-bolder">Thank you for your payment!</p>
          <p id="paragraph_thank_you_message1" class="text-center lh-sm">A receipt will be emailed to you shortly.</p>
        </div>
        <div class="modal-footer justify-content-between">
          <button class="btn btn-success" data-bs-dismiss="modal" id="button_make_another_payment" is="dmx-button" value="" type="button">Make Another Payment</button>
          <button class="btn btn-success" data-bs-dismiss="modal" id="button_view_receipt" is="dmx-button" value="" type="button">View Payment Receipt</button>
          <button class="btn btn-success" data-bs-dismiss="modal" id="button_view_receipt_subscription" is="dmx-button" value="" type="button" style="display: none !important;">View Recurring Recap</button>
        </div>
      </div>
    </div>
  </div>
  <div class="modal" id="modal_payment_submission" is="dmx-bs5-modal" tabindex="-1" style="display: none !important;">
    <div class="modal-dialog" role="document">
      <div class="modal-content">
        <div class="modal-header">
          <h5 class="modal-title text-success fw-bolder">Payment Submission</h5>
          <button class="btn-close" data-bs-dismiss="modal" aria-label="Close" is="dmx-button" value="" type="button"></button>
        </div>
        <div class="modal-body">
          <p id="paragraph_thank_you_message2" class="text-center fw-bolder">Thank you for your payment!</p>
          <p id="paragraph_thank_you_message2" class="text-center lh-sm">A receipt will be emailed to you shortly.</p>
        </div>
        <div class="modal-footer justify-content-between">
          <button class="btn btn-success" data-bs-dismiss="modal" id="button_make_another_payment2" is="dmx-button" value="" type="button">Make Another Payment</button>
          <button class="btn btn-success" data-bs-dismiss="modal" id="button_view_receipt1" is="dmx-button" value="" type="button">View Payment Receipt</button>
          <button class="btn btn-success" data-bs-dismiss="modal" id="button_view_receipt_subscription1" is="dmx-button" value="" type="button" style="display: none !important;">View Recurring Recap</button>
        </div>
      </div>
    </div>
  </div>
  <div class="modal" id="modal_payment_manual" is="dmx-bs5-modal" tabindex="-1">
    <div class="modal-dialog" role="document">
      <div class="modal-content">
        <div class="modal-header">
          <h5 class="modal-title text-success fw-bolder">Payment by Other Methods</h5>
          <button class="btn-close" data-bs-dismiss="modal" aria-label="Close" is="dmx-button" value="" type="button"></button>
        </div>
        <div class="modal-body bg-opacity-10 bg-success">
          <p id="para_text_message" class="text-justify"></p>
          <div class="container" id="container_manual_payment_address">
            <p id="para_address_header" class="text-justify">Our office is located at:</p>
            <p id="para_address_line_1" class="text-center mb-0">635 NW 7th Street</p>
            <p id="para_address_line_2" class="text-center mb-0" style="display: none !important;"></p>
            <p id="para_address_city_state_zip" class="text-center">Oklahoma City, Oklahoma 73160</p>
          </div>
          <div class="container" id="container_manual_payment_phone">
            <p id="para_phone_header" class="text-justify">Our office phone number is:</p>
            <p id="para_phone" class="text-center">(405) 467-9121</p>
          </div>
          <p id="para_thank_you" class="text-center lh-sm fw-bolder fst-italic">Thank you!</p>
        </div>
        <div class="modal-footer justify-content-between text-center">
          <button class="btn btn-success" data-bs-dismiss="modal" id="button_make_another_payment1" is="dmx-button" value="" type="button">Close</button>
        </div>
      </div>
    </div>
  </div>
  <div class="modal" id="modal_payment_error" data-backdrop="static" is="dmx-bs5-modal" tabindex="-1">
    <div class="modal-dialog" role="document">
      <div class="modal-content">
        <div class="modal-header">
          <h5 class="modal-title fw-bolder text-danger">Payment Submission Error</h5>
          <button class="btn-close" data-bs-dismiss="modal" aria-label="Close" is="dmx-button" value="" type="button"></button>
        </div>
        <div class="modal-body">
          <p class="text-center fw-bolder" id="para_response_text"></p>
          <p class="text-center fst-italic" id="para_duplicate_amount" style="display: none !important;">Please modify your payment amount and re-submit your payment.&nbsp; Thank you!</p>
          <p class="text-center fst-italic" id="psts_error">Please refresh your page and try your payment again, or contact your merchant for support! Thank you!</p>
        </div>
        <div class="modal-footer">
          <button class="btn btn-secondary" data-bs-dismiss="modal" is="dmx-button" value="" type="button">Close</button>
        </div>
      </div>
    </div>
  </div>
  <div class="modal" id="modal_payment_declined" is="dmx-bs5-modal" tabindex="-1">
    <div class="modal-dialog" role="document">
      <div class="modal-content">
        <div class="modal-header">
          <h5 class="modal-title fw-bolder text-danger">Payment Declined</h5>
          <button class="btn-close" data-bs-dismiss="modal" aria-label="Close" is="dmx-button" value="" type="button"></button>
        </div>
        <div class="modal-body">
          <p id="para_declined_message">Your payment was declined.</p>
          <p id="para_response_text">Please re-enter your card information, try a different payment method, or try a different card.</p>
        </div>
        <div class="modal-footer">
          <button class="btn btn-secondary" data-bs-dismiss="modal" is="dmx-button" value="" type="button">Close</button>
        </div>
      </div>
    </div>
  </div>
  <div class="modal" id="modal_recurring_desc" is="dmx-bs5-modal" tabindex="-1">
    <div class="modal-dialog" role="document">
      <div class="modal-content">
        <div class="modal-header">
          <h5 class="modal-title">What is a Recurring Payment?</h5>
          <button class="btn-close" data-bs-dismiss="modal" aria-label="Close" is="dmx-button" value="" type="button"></button>
        </div>
        <div class="modal-body bg-success">
          <p class="text-light text-center">A Recurring Payment is a payment model where you, the customer, authorize the merchant to pull funds from your account automatically at regular intervals for the goods and services provided to you on an
            ongoing basis.<br><br><strong>NOTE: No payment will be charged to your account today when a recurring payment is setup!</strong></p>
        </div>
        <div class="modal-footer">
          <button class="btn btn-secondary" data-bs-dismiss="modal" is="dmx-button" value="" type="button">Close</button>
        </div>
      </div>
    </div>
  </div>
  <div class="modal" id="modal_inactive" is="dmx-bs5-modal" tabindex="-1">
    <div class="modal-dialog" role="document">
      <div class="modal-content">
        <div class="modal-header">
          <h5 class="modal-title">Inactive Merchant</h5>
          <button class="btn-close" data-bs-dismiss="modal" aria-label="Close" is="dmx-button" value="" type="button"></button>
        </div>
        <div class="modal-body bg-danger">
          <p class="text-center text-light">This payment page is not currently active.&nbsp; Please contact your merchant for assistance.&nbsp; Thank you!</p>
        </div>
        <div class="modal-footer" style="display: none !important;">
          <button class="btn btn-secondary disabled visually-hidden" data-bs-dismiss="modal" id="button_close_inactive_modal" is="dmx-button" value="" type="button">Close</button>
        </div>
      </div>
    </div>
  </div>
  <section id="hidden_fields">
    <input id="client_ip" name="client_ip" class="form-control" type="hidden" is="dmx-input" value="">
    <input id="access_log_uid" name="access_log_uid" class="form-control" type="hidden" is="dmx-input" value="1646">
    <input id="show_orig_payment_amount_in_order_desc" name="show_orig_payment_amount_in_order_desc" class="form-control" type="hidden" is="dmx-input" value="No">
    <input id="cureclick_id" name="cureclick_id" class="form-control" type="hidden" is="dmx-input" value="72220">
    <input id="cureclick_uid" name="cureclick_uid" class="form-control" type="hidden" is="dmx-input" value="23">
    <input id="merchant_uid" name="merchant_uid" class="form-control" type="hidden" is="dmx-input" value="24592">
    <input id="client_country_city_vpn" name="client_country_city_vpn" class="form-control" type="hidden" is="dmx-input" value="">
    <input id="order_id" name="order_id" class="form-control" type="hidden" is="dmx-input" value="20231113-074221-57701570">
    <input id="api_key" name="api_key" class="form-control" type="hidden" is="dmx-input" value="KjJkEcyTpghedDY9C6C6ej48ZMg7dZWg"><input id="raw_response" name="raw_response" type="hidden" class="form-control" is="dmx-input" value="">
    <input id="response" name="response" type="hidden" class="form-control" is="dmx-input" value="">
    <input id="token_key" name="token_key" class="form-control" type="hidden" is="dmx-input" value="qnpVfZ-3uq522-3FNedj-6s8679">
    <input id="token_response_key" name="token_response_key" class="form-control" type="hidden" is="dmx-input" value="">
    <input id="payment_type" name="payment_type" type="hidden" class="form-control" is="dmx-input" value="">
    <input id="admin_fee" name="admin_fee" type="hidden" class="form-control" is="dmx-input" value="0"><input id="admin_fee_percent" name="admin_fee_percent" type="hidden" class="form-control" is="dmx-input" value="3.9900">
    <input id="total_payment_amount" name="total_payment_amount" type="hidden" class="form-control" is="dmx-input" value=""><input id="total_payment_amount_card" name="total_payment_amount_card" type="hidden" class="form-control" is="dmx-input"
      value="">
    <input id="total_payment_amount_ach" name="total_payment_amount_ach" type="hidden" class="form-control" is="dmx-input" value="">
    <input id="total_payment_amount_other" name="total_payment_amount_other" type="hidden" class="form-control" is="dmx-input" value="">
    <input id="card_processor" name="card_processor" type="hidden" class="form-control" is="dmx-input" value="NMI">
    <input id="ach_processor" name="ach_processor" type="hidden" class="form-control" is="dmx-input" value="NMI">
  </section>
  <section class="visually-hidden">
    <div class="container">
      <div class="row">
        <div class="col text-center">
          <img id="captureimage" class="visually-hidden">
          <button id="screen_capture" class="btn btn-success" onclick="captureScreen()" is="dmx-button" value="" type="button">Screen Capture</button>
        </div>
      </div>
    </div>
  </section>
  <section id="payer_section" class="border-success border-5 rounded rounded-3 container-fluid">
    <div class="row justify-content-center pb-0" id="row_payer">
      <div class="col-12 col-md-8 col-lg-8 col-xl-6">
        <div class="row">
          <div class="col text-center">
            <h1 id="payee_header">Payer</h1>
          </div>
        </div>
        <div class="row align-items-center mt-0" id="payer_name">
          <div class="col-xs-12 col-md-6 mt-xs-2 mt-md-4">
            <h6 id="heading_first_name">First Name *</h6>
            <input type="text" id="input_first_name" name="first_name" class="form-control" placeholder="First Name" required="" autofocus="" is="dmx-input" value="">
          </div>
          <div class="col-xs-12 col-md-6 mt-xs-2 mt-md-4">
            <h6 id="heading_last_name">Last Name *</h6><input type="text" id="input_last_name" name="last_name" class="form-control" placeholder="Last Name" required="" is="dmx-input" value="">
          </div>
        </div>
        <div class="row align-items-center mt-0" id="company_phone">
          <div class="col-xs-12 col-md-6 mt-xs-2 mt-md-4" id="col_company" style="">
            <h6 id="heading_company">Company</h6>
            <h6 id="heading_company_required" style="display: none !important;">Company *</h6>
            <input type="text" id="input_company" name="company" class="form-control" placeholder="Company Name" is="dmx-input" value="">
          </div>
          <div class="col-xs-12 col-md-6 mt-xs-2 mt-md-4" id="col_phone" style="">
            <h6 id="heading_phone">Phone</h6>
            <h6 id="heading_phone_required" style="display: none !important;">Phone *</h6>
            <input type="text" id="input_phone" name="phone" class="form-control" placeholder="Phone" is="dmx-input" value="">
          </div>
        </div>
        <div class="row align-items-center mt-0" id="payer_email">
          <div class="col-xs-12 col-md-6 mt-xs-2 mt-md-4">
            <h6 id="heading_email">Email *</h6>
            <input type="email" id="input_email" name="email" class="form-control" placeholder="Email" required="" data-rule-email="" is="dmx-input" value="">
          </div>
          <div class="col-xs-12 col-md-6 mt-xs-2 mt-md-4">
            <h6 id="heading_confirm_email">Confirm Email *</h6>
            <input type="email" id="input_email1" name="confirm_email" class="form-control" placeholder="Confirm Email" required="" data-rule-email="" data-rule-equalto="email" data-msg-equalto="Please enter the same email again." is="dmx-input"
              value="">
          </div>
        </div>
      </div>
    </div>
    <div class="row justify-content-center mt-5 mb-4" id="row_payer_address">
      <div class="col-12 col-md-8 col-lg-8 col-xl-6 border rounded border-primary border-1 rounded-2">
        <div class="row">
          <div class="col text-center">
            <h4 id="payee_address_header">Payer Address</h4>
          </div>
        </div>
        <div class="row align-items-center" id="payer_address">
          <div class="col-xs-12 col-md-6 mt-xs-2 mt-md-4" id="col_address_line_1">
            <h6 id="heading_address_line_1">Address Line 1 *</h6>
            <input type="text" id="input_payer_address_line_1" name="payer_address_line_1" class="form-control" placeholder="Address Line 1" is="dmx-input" value="">
          </div>
          <div class="col-xs-12 col-md-6 mt-xs-2 mt-md-4" id="col_address_line_2">
            <h6 id="heading_address_line_2">Address Line 2</h6>
            <input type="text" id="input_payer_address_line_2" name="payer_address_line_2" class="form-control" placeholder="Address Line 2" is="dmx-input" value="">
          </div>
        </div>
        <div class="row align-items-center mb-2" id="row_city_state">
          <div class="col-xs-12 col-md-4 mt-xs-2 mt-md-4" id="col_city">
            <h6 id="heading_city">City</h6>
            <input type="text" id="input_city" name="city" class="form-control " placeholder="City Name" is="dmx-input" value="">
          </div>
          <div class="col-xs-12 col-md-4 mt-xs-2 mt-md-4" id="col_state">
            <h6 id="heading_state">State</h6>
            <input type="text" id="input_state" name="state" class="form-control" placeholder="State" is="dmx-input" value="">
          </div>
          <div class="col-xs-12 col-md-4 mt-xs-2 mt-md-4" id="col_zip_code">
            <h6 id="heading_zip_code">Zip Code *</h6><input id="input_zip_code" name="zip_code" class="form-control" placeholder="Zip Code" is="dmx-input" value="">
          </div>
        </div>
      </div>
    </div>
  </section>
  <section id="reference_section" class="border-success border-5 rounded rounded-3 container-fluid">
    <div class="row justify-content-center pb-0" id="row_reference">
      <div class="col-12 col-md-8 col-lg-8 col-xl-6">
        <div class="row" id="row_reference_header">
          <div class="col text-center">
            <h1 id="reference_header">Payment Reference</h1>
          </div>
        </div>
        <div class="row" id="row_order_id">
          <div class="col text-center">
            <p id="order_id_display" class="text-center fw-bold text-success bg-opacity-25 bg-warning">Order ID: 20231113-074221-57701570</p>
          </div>
        </div>
        <div class="row align-items-center" id="row_reference_1" style="">
          <div class="col mt-0">
            <input id="title_reference_1" name="title_reference_1" type="hidden" class="form-control" is="dmx-input" value="Payment Reference">
            <h6 id="heading_reference_1">Payment Reference</h6>
            <h6 id="heading_reference_1_required" style="display: none !important;">Payment Reference *</h6>
            <textarea id="input_reference_1" class="form-control" name="input_reference_1" is="dmx-textarea"></textarea>
          </div>
        </div>
        <div class="row align-items-center" id="row_reference_2" style="display: none !important;">
          <div class="col mt-4">
            <input id="title_reference_2" name="title_reference_2" type="hidden" class="form-control" is="dmx-input" value="">
            <h6 id="heading_reference_2"></h6>
            <h6 id="heading_reference_2_required"> *</h6>
            <textarea id="input_reference_2" class="form-control" name="input_reference_2" is="dmx-textarea"></textarea>
          </div>
        </div>
        <div class="row align-items-center" id="row_reference_3" style="display: none !important;">
          <div class="col mt-4">
            <input id="title_reference_3" name="title_reference_3" type="hidden" class="form-control" is="dmx-input" value="">
            <h6 id="heading_reference_3"></h6>
            <h6 id="heading_reference_2_required1"> *</h6>
            <textarea id="input_reference_3" class="form-control" name="input_reference_3" is="dmx-textarea"></textarea>
          </div>
        </div>
      </div>
    </div>
  </section>
  <section id="recurring_section" class="border-success border-5 rounded rounded-3 container-fluid mt-4" style="display: none !important;">
    <div class="row justify-content-center pb-0" id="row_recurring">
      <div class="col-12 col-md-8 col-lg-8 col-xl-6">
        <div class="row" id="row_recurring_header">
          <div class="col text-center">
            <h1 id="recurring_header">Recurring Payment Setup</h1>
          </div>
        </div>
        <div class="row" id="row_recurring_description">
          <div class="col text-center">
            <p id="paragraph_recurring_description" class="text-center fw-bold bg-opacity-25 bg-warning mt-0 mb-0 text-success fst-italic"><u>What is a Recurring Payment?</u></p>
            <p id="paragraph_recurring_warning" class="text-center bg-opacity-25 bg-warning fw-bolder text-dark visually-hidden">(NOTE: No payment will be charged to your account today when a recurring payment is setup!)</p>
          </div>
        </div>
        <div class="row mt-2" id="row_recurring_checkbox">
          <div class="col text-center bg-success mt-2 mb-2 pt-2 pb-2">
            <div class="form-check form-check-inline">
              <input class="form-check-input" type="checkbox" id="checkbox_recurring" name="checkbox_recurring" is="dmx-checkbox" value="Checked">
              <label class="form-check-label col fw-bold text-white" for="checkbox_recurring" id="label_checkbox_recurring">Setup a Recurring Payment plan?</label>
            </div>
          </div>
        </div>
        <div class="row" id="row_recurring_frequency" style="display: none !important;">
          <div class="col mt-0">
            <div class="form-group text-left mb-4" is="dmx-radio-group" id="group_recurring_frequency"><label class="fw-bold">Frequency*</label>
              <div class="form-check">
                <input class="form-check-input" type="radio" id="radio_recurring_weekly" name="recurring_frequency" is="dmx-radio" value="weekly">
                <label class="form-check-label" for="radio_recurring_weekly">Weekly</label>
              </div>
              <div class="form-check">
                <input class="form-check-input" type="radio" id="radio_recurring_bi_weekly" name="recurring_frequency" is="dmx-radio" value="bi-weekly">
                <label class="form-check-label" for="radio_recurring_bi_weekly">Bi-Weekly (once every 14 days)</label>
              </div>
              <div class="form-check">
                <input class="form-check-input" type="radio" id="radio_recurring_monthly" name="recurring_frequency" is="dmx-radio" value="monthly" checked="">
                <label class="form-check-label" for="radio_recurring_monthly">Monthly</label>
              </div>
              <div class="form-check">
                <input class="form-check-input" type="radio" id="radio_recurring_bi_monthly" name="recurring_frequency" is="dmx-radio" value="bi-monthly">
                <label class="form-check-label" for="radio_recurring_bi_monthly">Bi-Monthly (once every 2 months)</label>
              </div>
              <div class="form-check">
                <input class="form-check-input" type="radio" id="radio_recurring_quarterly" name="recurring_frequency" is="dmx-radio" value="quarterly">
                <label class="form-check-label" for="radio_recurring_quarterly">Quarterly (once every 3 months)</label>
              </div>
              <div class="form-check">
                <input class="form-check-input" type="radio" id="radio_recurring_semi_annually" name="recurring_frequency" is="dmx-radio" value="semi-annually">
                <label class="form-check-label" for="radio_recurring_semi_annually">Semi-Annually (once every 6 months)</label>
              </div>
              <div class="form-check">
                <input class="form-check-input" type="radio" id="radio_recurring_annually" name="recurring_frequency" is="dmx-radio" value="annually">
                <label class="form-check-label" for="radio_recurring_annually">Annually (once every 12 months)</label>
              </div>
            </div>
          </div>
        </div>
        <div class="row" id="row_recurring_period" style="display: none !important;">
          <div class="col mt-0">
            <div class="form-group text-left mb-4" is="dmx-radio-group" id="group_recurring_period"><label class="fw-bold">Period *</label>
              <div class="form-check">
                <input type="radio" class="form-check-input" id="radio_recurring_specified_number_of_payments" name="radio_recurring_period" is="dmx-radio" value="Number of Payments" checked="">
                <label class="form-check-label" for="radio_recurring_specified_number_of_payments">Specified Number of Payments</label>
              </div>
              <div class="form-check">
                <input type="radio" class="form-check-input" id="radio_recurring_continue_until_cancelled" name="radio_recurring_period" is="dmx-radio" value="Until Cancelled">
                <label class="form-check-label" for="radio_recurring_continue_until_cancelled">Continue Until Cancelled</label>
              </div>
            </div>
          </div>
        </div>
        <div class="row" id="row_recurring_dates" style="display: none !important;">
          <div class="col mt-0" id="col_recurring_first_payment_date">
            <h6 id="heading_first_payment_date">First Payment Date *</h6>
            <input type="hidden" name="first_payment_date" value=""><input id="first_payment_date" is="dmx-date-picker" value="" autocomplete="off">
          </div>
          <div class="col mt-0" id="col_recurring_number_of_payments" style="">
            <h6 id="heading_recurring_number_of_payments">Number of Payments:</h6>
            <input id="text_recurring_number_of_payments" name="text_recurring_number_of_payments" type="number" class="form-control" is="dmx-input" value="">
          </div>
        </div>
      </div>
    </div>
  </section>
  <section id="amount_section" class="mt-5">
    <div class="row justify-content-center" id="row_amounts">
      <div class="col-12 col-md-8 col-lg-8 col-xl-6" id="col_amounts">
        <div class="row" id="row_amount_heading">
          <div class="col text-center" id="col_reference_heading1">
            <h1 id="amount_header">Payment Detail</h1>
          </div>
        </div>
        <div class="row align-items-center justify-content-around" id="row_amounts">
          <div class="col mt-4 col-6" id="col_payment_amount">
            <h6 id="heading_payment_amount">Payment Amount</h6><input id="input_payment_amount" name="payment_amount" type="number" class="form-control" min="1" data-msg-min="Please enter a value greater than or equal to $1." data-rule-min="1"
              placeholder="Payment Amount" required="" is="dmx-input" value="">
          </div>
          <div class="col mt-4 col-6" id="col_tip_amount" style="display: none !important;">
            <h6 id="heading_tip_amount">Tip Amount</h6><input id="input_tip_amount" name="tip_amount" type="number" class="form-control" placeholder="Tip Amount" is="dmx-input" value="">
          </div>
        </div>
      </div>
    </div>
    <div class="row justify-content-center" id="row_payment_methods">
      <div class="col-12 col-md-8 col-lg-8 col-xl-6 mt-2" id="col_payment_methods">
        <div class="row align-items-center" id="row_payment_methods_header" style="display: none !important;">
          <div class="col mt-4 text-center" id="col_payment_methods_header">
            <p class="fw-bolder mb-0" id="paragraph_payment_methods_header">Please select your method of payment:</p>
          </div>
        </div>
        <div class="row align-items-center mt-0 justify-content-around" id="row_payment_methods_buttons" style="display: none !important;">
          <div class="col-xs-12 col-md-4 mt-xs-2 text-center" id="col_pay_by_card" style="">
            <button id="button_pay_by_card" class="btn btn-primary fw-bolder mt-2 shadow-lg border border-dark border-3" onclick="load_collectjs('Card');" data-bs-trigger="hover" is="dmx-button" value="" disabled="" type="button"
              data-bs-original-title="" title="" tooltip-title="Pay by Card" style="background-color: rgb(98, 170, 218) !important; color: rgb(255, 255, 255) !important;">Pay $0.00 by Card</button>
          </div>
          <div class="col-xs-12 col-md-4 mt-xs-2 text-center" id="col_pay_by_ach" style="">
            <button id="buttn_pay_by_ach" class="btn btn-primary fw-bolder mt-2 shadow-lg border border-dark border-3" data-bs-trigger="hover" onclick="load_collectjs('ACH');" is="dmx-button" value="" disabled="" type="button"
              data-bs-original-title="" title="" tooltip-title="Pay by ACH or Electronic Check." style="background-color: rgb(98, 170, 218) !important; color: rgb(255, 255, 255) !important;">Pay $0.00 by ACH</button>
          </div>
          <div class="col-xs-12 col-md-4 mt-xs-2 text-center" id="col_pay_by_other" style="display: none !important;">
            <button id="buttn_pay_by_other" class="btn fw-bolder mt-2 shadow-lg border border-dark border-3 style1" data-bs-trigger="hover" is="dmx-button" value="" disabled="" type="button" data-bs-original-title="" title=""
              tooltip-title="Pay by Other Means" style="background-color: rgb(98, 170, 218) !important; color: rgb(255, 255, 255) !important;">Pay $0.00 by Other</button>
          </div>
        </div>
      </div>
    </div>
    <div class="row justify-content-center mt-4" id="row_payment_vault" style="display: none !important;">
      <div class="col-12 col-md-8 col-lg-8 col-xl-6 border border-4 rounded rounded-2 border-warning" id="col_payment_vault">
        <div class="row" id="row_amount_heading1">
          <div class="col text-center" id="col_reference_heading2">
            <h4 id="amount_header1">Payment Vault</h4>
          </div>
        </div>
        <div class="row align-items-center mt-2 mb-2" id="row_add_to_vault">
          <div class="col text-center mt-0" id="col_add_to_vault">
            <div class="form-check form-check-inline">
              <input class="form-check-input" type="checkbox" id="checkbox_add_to_vault" name="checkbox_add_to_vault" is="dmx-checkbox" value="1">
              <label class="form-check-label" for="checkbox_add_to_vault" id="label_add_to_vault"><b>I authorize my payment information be saved, in a secure tokenized and encrypted manner, for future transactions!</b></label>
            </div>
          </div>
        </div>
      </div>
    </div>
    <div class="row justify-content-center mt-4" id="row_payment_buttons" style="display: none !important;">
      <div class="col-12 col-md-8 col-lg-8 col-xl-6 border border-4 rounded rounded-2 border-success" id="col_payment_buttons">
        <div class="row align-items-center" id="row_payment_verbiage">
          <div class="col text-center mt-0" id="col_pay_by_other1">
            <p id="paragraph_submit_verbiage_card" class="fw-bolder fst-italic mt-2 bg-success text-white lh-lg">Your payment will be $0.00 via Card.</p>
            <p id="paragraph_submit_verbiage_ach" class="fst-italic mt-2 bg-success text-white fw-bolder lh-lg">Your payment will be $0.00 via Electronic Check.</p>
            <p id="paragraph_submit_button1" class="fst-italic mt-2">If this is correct, press 'Submit Payment' button to finalize your payment!<br>If this is not correct, please change your payment method above!</p>
          </div>
        </div>
        <div class="row align-items-center mb-2">
          <div class="col text-center mt-0" id="col_pay_by_other2">
            <button id="btn_submit_payment" class="btn btn-primary fw-bolder lh-lg bg-success" is="dmx-button" value="" disabled="" type="submit">Submit Payment </button>
          </div>
        </div>
      </div>
    </div>
  </section>
</form>

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Our office is located at:

635 NW 7th Street



Oklahoma City, Oklahoma 73160

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(405) 467-9121

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PAYER

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LAST NAME *

COMPANY

COMPANY *

PHONE

PHONE *

EMAIL *

CONFIRM EMAIL *

PAYER ADDRESS

ADDRESS LINE 1 *

ADDRESS LINE 2

CITY

STATE

ZIP CODE *


PAYMENT REFERENCE

Order ID: 20231113-074221-57701570

PAYMENT REFERENCE

PAYMENT REFERENCE *

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RECURRING PAYMENT SETUP

What is a Recurring Payment?

(NOTE: No payment will be charged to your account today when a recurring payment
is setup!)

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Weekly
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Annually (once every 12 months)
Period *
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FIRST PAYMENT DATE *

NUMBER OF PAYMENTS:


PAYMENT DETAIL

PAYMENT AMOUNT

TIP AMOUNT

Please select your method of payment:

Pay $0.00 by Card
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Pay $0.00 by Other

PAYMENT VAULT

I authorize my payment information be saved, in a secure tokenized and encrypted
manner, for future transactions!

Your payment will be $0.00 via Card.

Your payment will be $0.00 via Electronic Check.

If this is correct, press 'Submit Payment' button to finalize your payment!
If this is not correct, please change your payment method above!

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All Payments made via this page will be submitted to:

Dynamic Driving LLC

Oklahoma City, Oklahoma 73160

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