secure.cardknox.com
Open in
urlscan Pro
52.39.105.55
Public Scan
URL:
https://secure.cardknox.com/egps
Submission: On July 25 via manual from IN — Scanned from DE
Submission: On July 25 via manual from IN — Scanned from DE
Form analysis 1 forms found in the DOM
POST /egps
<form action="/egps" id="process_cc_form" method="post">
<div class="form-content">
<div class="wrapleft tab_NewTransaction tabsDiv">
<div class="module">
<span class="header"> Billing Information </span>
<div class="grid">
<div class="grid_item"> <label id="lbl_xBillLastName" for="xBillLastName" class="label required">Name</label>
<input type="text" id="xBillLastName" name="xBillLastName" class="input required" value="">
</div>
<div class="grid_item"> <label id="lbl_xBillStreet" for="xBillStreet" class="label ">Street</label>
<input type="text" id="xBillStreet" name="xBillStreet" class="input" value="">
</div>
<div class="grid_item no_margin">
<div class="group">
<div class="grid_item">
<div class="inputmulti xBillCity">
<label for="xBillCity" class="label ">City</label>
<input type="text" id="xBillCity" name="xBillCity" class="input" value="">
</div>
</div>
<div class="grid_item">
<div class="inputmulti xBillState">
<label for="xBillState" class="label ">State</label>
<select name="xBillState" id="xBillState" class="input">
<option value="" selected="selected"></option>
<option value="AL">AL</option>
<option value="AK">AK</option>
<option value="AZ">AZ</option>
<option value="AR">AR</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="IA">IA</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="ME">ME</option>
<option value="MD">MD</option>
<option value="MA">MA</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MS">MS</option>
<option value="MO">MO</option>
<option value="MT">MT</option>
<option value="NE">NE</option>
<option value="NV">NV</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NY">NY</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="PR">PR</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VT">VT</option>
<option value="VA">VA</option>
<option value="WA">WA</option>
<option value="WV">WV</option>
<option value="WI">WI</option>
<option value="WY">WY</option>
</select>
</div>
</div>
<div class="grid_item">
<div class="inputmulti xBillZip">
<label for="xBillZip" class="label required">Zip</label>
<input type="text" id="xBillZip" name="xBillZip" class="input required" value="">
</div>
</div>
</div>
</div>
<div class="grid_item"> <label id="lbl_xBillPhone" for="xBillPhone" class="label ">Phone</label>
<input type="text" id="xBillPhone" name="xBillPhone" class="input" value="">
</div>
<div class="grid_item"> <label id="lbl_xEmail" for="xEmail" class="label required">Email</label>
<input type="text" id="xEmail" name="xEmail" class="input required" value="">
</div>
</div>
</div>
<div class="module">
<span class="header"> Transaction Details </span>
<div class="grid">
<div class="grid_item"> <label id="lbl_xCustom03" for="xCustom03" class="label required">Plan Name</label>
<input type="text" id="xCustom03" name="xCustom03" class="input required" value="">
</div>
<div class="grid_item"> <label id="lbl_xInvoice" for="xInvoice" class="label required">Invoice Number</label>
<div id="xInvoiceMaxLengthError" class="label" style="color: red; display:none ">Invoice cannot exceed 190 characters</div>
<input type="text" id="xInvoice" name="xInvoice" class="input required" value="">
</div>
<div class="grid_item"> <label id="lbl_xCustom09" for="xCustom09" class="label hidden">Custom 09</label>
<input type="text" id="xCustom09" name="xCustom09" class="input hidden" value="">
</div>
<div class="grid_item"> <label id="lbl_xCustom10" for="xCustom10" class="label hidden">Custom 10</label>
<input type="text" id="xCustom10" name="xCustom10" class="input hidden" value="">
</div>
<div class="grid_item"> <label id="lbl_xAmount" for="xAmount1" class="label required">Amount</label>
<div class="amount-input"><span class="currency">$</span><input type="number" step=".01" id="xAmount1" autocomplete="off" class="input required" value="" style="padding-left: 16px;"><input id="xAmount" name="xAmount"
class="input required hidden" value="" type="text"></div>
</div>
</div>
</div>
<div>
</div>
<div>
<div name="h-captcha" class="h-captcha" data-sitekey="921ca4c2-5606-4dcf-8248-ec26f78f062b"><iframe
src="https://newassets.hcaptcha.com/captcha/v1/8a97127/static/hcaptcha.html#frame=checkbox&id=0ng6sxwvqxnp&host=secure.cardknox.com&sentry=true&reportapi=https%3A%2F%2Faccounts.hcaptcha.com&recaptchacompat=true&custom=false&hl=en&tplinks=on&sitekey=921ca4c2-5606-4dcf-8248-ec26f78f062b&theme=light&origin=https%3A%2F%2Fsecure.cardknox.com"
tabindex="0" frameborder="0" scrolling="no" title="Widget containing checkbox for hCaptcha security challenge" data-hcaptcha-widget-id="0ng6sxwvqxnp" data-hcaptcha-response=""
style="width: 303px; height: 78px; overflow: hidden;"></iframe><textarea id="g-recaptcha-response-0ng6sxwvqxnp" name="g-recaptcha-response" style="display: none;"></textarea><textarea id="h-captcha-response-0ng6sxwvqxnp"
name="h-captcha-response" style="display: none;"></textarea></div>
</div>
</div>
<div class="wrapright tab_NewTransaction tabsDiv">
<div class="wraprightabsolute absolute" style="top: 0px;">
<div class="module border">
<div class="header">Payment Information</div>
<div class="grid">
<div id="div_cc_num" class="">
<div class="group">
<div class="grid">
<div class="grid_item">
<div class="label left">Payment Type</div>
<span class="right">
<input type="radio" name="pt" id="ptCc" value="CC" checked="">
<label for="ptCc" class="">Credit Card</label> <input type="radio" name="pt" id="ptAch" value="ACH" class="is-active">
<label for="ptAch" class="">Check</label>
</span>
</div>
</div>
</div>
<div class="group">
<div class="grid_item hidden">
<span class="right cards ccField hidden">
<img class="" src="https://secure-cdn.cardknox.com/content/themes/grey/Icons/4_card.png" width="34" id="visa" alt="Visa">
<img class="" src="https://secure-cdn.cardknox.com/content/themes/grey/Icons/5_card.png" width="34" id="mc" alt="MasterCard">
<img class="" src="https://secure-cdn.cardknox.com/content/themes/grey/Icons/6_card.png" width="34" id="disc" alt="Discover">
<img class="" src="https://secure-cdn.cardknox.com/content/themes/grey/Icons/3_card.png" width="34" id="amex" alt="American Express">
</span>
</div>
<div class="grid_item hidden">
<label id="lbl_xCardNum" for="xCardNum" class="label ccField left required hidden">Card Number</label>
<input type="text" autocomplete="off" inputmode="numeric" id="xCardNum" name="xCardNum" class="input required ccField integer fs-exclude hidden">
<input type="hidden" name="xMagstripe" id="xMagstripe" disabled="disabled">
<a href="#0" class="edit-card-num hidden">Change Card Number</a>
<input type="hidden" class="hidden" id="xCCToken" name="xToken" disabled="disabled">
</div>
</div>
<div class="grid ccField ccInfo group hidden">
<div class="grid_item hidden">
<!-- Begin Expiration -->
<div class="expiration left">
<label class="label ccField required hidden" id="lbl_exp" for="exp">Expiration</label>
<select class="input required exp" id="exp" name="ccExpMonth">
<option selected="" hidden="" value=""></option>
<option>01</option>
<option>02</option>
<option>03</option>
<option>04</option>
<option>05</option>
<option>06</option>
<option>07</option>
<option>08</option>
<option>09</option>
<option>10</option>
<option>11</option>
<option>12</option>
</select>
<select class="input required exp" id="ccExpYear" name="ccExpYear">
<option selected="" hidden="" value=""></option>
<option>23</option>
<option>24</option>
<option>25</option>
<option>26</option>
<option>27</option>
<option>28</option>
<option>29</option>
<option>30</option>
<option>31</option>
<option>32</option>
<option>33</option>
<option>34</option>
<option>35</option>
<option>36</option>
<option>37</option>
<option>38</option>
<option>39</option>
<option>40</option>
<option>41</option>
<option>42</option>
<option>43</option>
<option>44</option>
<option>45</option>
<option>46</option>
<option>47</option>
<option>48</option>
<option>49</option>
<option>50</option>
<option>51</option>
<option>52</option>
<option>53</option>
<option>54</option>
<option>55</option>
<option>56</option>
<option>57</option>
<option>58</option>
<option>59</option>
<option>60</option>
<option>61</option>
<option>62</option>
<option>63</option>
<option>64</option>
<option>65</option>
<option>66</option>
<option>67</option>
<option>68</option>
<option>69</option>
<option>70</option>
<option>71</option>
<option>72</option>
<option>73</option>
</select>
</div>
<!-- End Expiration -->
<!-- Begin CVV -->
<div class="right cvvD" id="div_cvv">
<label class="label ccField required hidden" id="lbl_xCVV" for="xCVV"> CVV </label>
<input type="text" inputmode="numeric" autocomplete="off" id="xCVV" name="xCVV" maxlength="4" class="input wInfo required fs-exclude">
<span class="infoI" style="margin: 0" id="cvvB">i</span>
</div>
<!-- End CVV -->
</div>
</div>
</div>
<div id="command_type" class="ccField hidden">
<div class="grid_item">
<input type="hidden" id="xCommand" name="xCommand" value="cc:sale">
</div>
</div>
<div class="achDiv">
<div class="grid">
<div class="grid_item">
<label class="label required achField" for="xAccountType">Account Type</label>
<select id="xAccountType" name="xAccountType" class="select required achField">
<option value="">Select One</option>
<option value="Checking">Checking</option>
<option value="Savings">Savings</option>
</select>
</div>
<div class="grid_item">
<label class="label required achField" for="xName">Name on Account</label>
<input type="text" id="xName" name="xName" class="input required achField">
</div>
<div class="grid_item">
<label class="label required achField" for="xRouting"> Routing Number </label>
<input type="text" id="xRouting" name="xRouting" class="input required achField wInfo integer">
<span id="routNum" style="margin: 0" class="infoI achField">i</span>
</div>
<div class="grid_item">
<label class="label required achField" for="xRouting2">Re-enter Routing Number</label>
<input id="xRouting2" class="input required achField integer" type="text" autocomplete="off">
</div>
<div class="grid_item">
<label class="label required achField" for="xAccount"> Account Number </label>
<input type="text" autocomplete="off" id="xAccount" name="xAccount" class="input required achField wInfo integer fs-exclude">
<span id="accNum" style="margin: 0" class="infoI achField">i</span>
</div>
<div class="grid_item">
<label class="label required achField" for="xAccount2">Re-enter Account Number</label>
<input id="xAccount2" class="input required achField integer fs-exclude" type="text" autocomplete="off">
</div>
<div class="grid_item">
<a href="#0" class="edit-account-info hidden">Change Acount Info</a>
<input type="hidden" class="hidden" id="xACHToken" name="xToken" disabled="disabled">
</div>
</div>
<div class="achagree achField">
<p id="pactsafe-authorization" data-all-agreed="false"></p>
<div id="ps-group-ps-ach-auth" class="ps-group ps-style-full" data-gid="35267" data-key="ps-ach-auth">
<style scoped="">
#ps-group-ps-ach-auth *,
#ps-group-ps-ach-auth div {
border: 0;
margin: 0;
padding: 0;
min-height: 0;
max-height: none;
min-width: 0;
max-width: none;
}
#ps-group-ps-ach-auth a {
font-size: 1em;
}
#ps-group-ps-ach-auth a:hover {
text-decoration: underline;
}
#ps-group-ps-ach-auth div,
#ps-group-ps-ach-auth p,
#ps-group-ps-ach-auth span {
color: #444;
}
#ps-group-ps-ach-auth div.ps-contract {
display: block;
padding: 0 0 25px;
margin: 0;
color: #444;
font-size: 13px;
line-height: 1.5;
}
#ps-group-ps-ach-auth div.ps-contract-title {
display: block;
margin: 0 0 10px;
font-size: 1.15em;
}
#ps-group-ps-ach-auth div.ps-contract-options {
display: block;
font-size: 0.9em;
height: auto;
background-color: #f6f6f6;
border: 1px solid #ddd;
border-bottom-width: 0;
padding: 7px 15px;
}
#ps-group-ps-ach-auth table.ps-contract-options-links {
border: 0;
border-collapse: collapse;
border-spacing: 0;
margin: 0;
width: 100%;
min-height: 33px;
}
#ps-group-ps-ach-auth table.ps-contract-options-links td {
padding: 0;
border: 0;
vertical-align: middle;
}
#ps-group-ps-ach-auth td.ps-contract-options-left {
text-align: left;
width: 50%;
}
#ps-group-ps-ach-auth td.ps-contract-options-right {
text-align: right;
width: 50%;
}
#ps-group-ps-ach-auth div.ps-expand-button {
display: block;
width: auto;
cursor: pointer;
}
#ps-group-ps-ach-auth a.ps-download-link {
display: inline-block;
}
#ps-group-ps-ach-auth div.ps-contract-body {
display: block;
border: 1px solid #ddd;
border-bottom-width: 0;
padding: 15px;
margin: 0;
font-size: 1em;
}
#ps-group-ps-ach-auth div.ps-contract-scroll {
max-height: 400px;
min-height: auto;
overflow: auto;
}
#ps-group-ps-ach-auth div.ps-contract-body span {
display: inline;
}
#ps-group-ps-ach-auth label.ps-checkbox-container {
display: block;
background-color: #f6f6f6;
border: 1px solid #ddd;
padding: 15px 15px 15px 36px;
text-transform: none;
font-size: 1em;
line-height: 1.65;
cursor: pointer;
}
#ps-group-ps-ach-auth input[type="checkbox"].ps-contract-target {
display: inline;
vertical-align: middle;
width: auto;
min-height: 0;
max-height: none;
min-width: 0;
max-width: none;
padding: 0;
margin: 0 0 0 -20px;
cursor: pointer;
}
#ps-group-ps-ach-auth div.ps-contract-label {
display: inline;
vertical-align: middle;
padding: 0;
margin: 0 0 0 6px;
}
#ps-group-ps-ach-auth a.ps-contract-link {
display: inline;
}
#ps-group-ps-ach-auth div.ps-contract-body h1,
#ps-group-ps-ach-auth div.ps-contract-body h2,
#ps-group-ps-ach-auth div.ps-contract-body h3,
#ps-group-ps-ach-auth div.ps-contract-body h4,
#ps-group-ps-ach-auth div.ps-contract-body h5,
#ps-group-ps-ach-auth div.ps-contract-body h6,
#ps-group-ps-ach-auth div.ps-contract-body p,
#ps-group-ps-ach-auth div.ps-contract-body blockquote,
#ps-group-ps-ach-auth div.ps-contract-body pre,
#ps-group-ps-ach-auth div.ps-contract-body a,
#ps-group-ps-ach-auth div.ps-contract-body abbr,
#ps-group-ps-ach-auth div.ps-contract-body address,
#ps-group-ps-ach-auth div.ps-contract-body cit,
#ps-group-ps-ach-auth div.ps-contract-body code,
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#ps-group-ps-ach-auth div.ps-contract-body dfn,
#ps-group-ps-ach-auth div.ps-contract-body em,
#ps-group-ps-ach-auth div.ps-contract-body ins,
#ps-group ps-ach-auth div.ps-contract-body q,
#ps-group-ps-ach-auth div.ps-contract-body samp,
#ps-group-ps-ach-auth div.ps-contract-body small,
#ps-group-ps-ach-auth div.ps-contract-body strong,
#ps-group-ps-ach-auth div.ps-contract-body sub,
#ps-group-ps-ach-auth div.ps-contract-body sup,
#ps-group-ps-ach-auth div.ps-contract-body b,
#ps-group-ps-ach-auth div.ps-contract-body i,
#ps-group-ps-ach-auth div.ps-contract-body hr,
#ps-group-ps-ach-auth div.ps-contract-body dl,
#ps-group-ps-ach-auth div.ps-contract-body dt,
#ps-group-ps-ach-auth div.ps-contract-body dd,
#ps-group-ps-ach-auth div.ps-contract-body ol,
#ps-group-ps-ach-auth div.ps-contract-body ul,
#ps-group-ps-ach-auth div.ps-contract-body li,
#ps-group-ps-ach-auth div.ps-contract-body fieldset,
#ps-group-ps-ach-auth div.ps-contract-body legend,
#ps-group-ps-ach-auth div.ps-contract-body label {
border: initial;
font-size: inherit;
vertical-align: initial;
margin: initial;
padding: initial;
}
#ps-group-ps-ach-auth div.ps-contract-body table {
border-collapse: collapse;
border-spacing: initial;
border: 1px solid #e2ebf2;
width: 100%;
}
#ps-group-ps-ach-auth div.ps-contract-body table caption,
#ps-group-ps-ach-auth div.ps-contract-body table th,
#ps-group-ps-ach-auth div.ps-contract-body table td {
text-align: left;
vertical-align: top;
}
#ps-group-ps-ach-auth div.ps-contract-body table td {
border: 1px solid #e2ebf2;
padding: 10px;
}
#ps-group-ps-ach-auth div.ps-contract-body a,
#ps-group-ps-ach-auth div.ps-contract-body a:focus,
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cursor: pointer;
text-decoration: initial;
}
#ps-group-ps-ach-auth div.ps-contract-body ol {
list-style-type: decimal;
padding: 0 0 0 40px;
list-style-position: outside;
}
#ps-group-ps-ach-auth div.ps-contract-body ol>li>ol {
list-style-type: lower-alpha;
}
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list-style-type: lower-roman;
}
#ps-group-ps-ach-auth div.ps-contract-body ul {
list-style-type: disc;
padding: 0 0 0 40px;
list-style-position: outside;
}
#ps-group-ps-ach-auth div.ps-contract-body ul>li>ul {
list-style-type: circle;
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list-style-type: square;
}
#ps-group-ps-ach-auth div.ps-contract-body blockquote {
padding: 0 40px;
}
#ps-group-ps-ach-auth div.ps-contract-body p {
font-size: 14px;
}
#ps-group-ps-ach-auth div.ps-contract-body h1,
#ps-group-ps-ach-auth div.ps-contract-body h2,
#ps-group-ps-ach-auth div.ps-contract-body h3,
#ps-group-ps-ach-auth div.ps-contract-body h4,
#ps-group-ps-ach-auth div.ps-contract-body h5,
#ps-group-ps-ach-auth div.ps-contract-body h6 {
font-weight: normal;
}
#ps-group-ps-ach-auth div.ps-contract-body h1 {
font-size: 32px;
}
#ps-group-ps-ach-auth div.ps-contract-body h2 {
font-size: 28px;
}
#ps-group-ps-ach-auth div.ps-contract-body h3 {
font-size: 24px;
}
#ps-group-ps-ach-auth div.ps-contract-body h4 {
font-size: 20px;
}
#ps-group-ps-ach-auth div.ps-contract-body h5 {
font-size: 18px;
}
#ps-group-ps-ach-auth div.ps-contract-body h6 {
font-size: 16px;
}
#ps-group-ps-ach-auth div.ps-contract-body {
color: #5d646f;
}
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#ps-group-ps-ach-auth div.ps-contract-body h2,
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#ps-group-ps-ach-auth div.ps-contract-body h4,
#ps-group-ps-ach-auth div.ps-contract-body h5,
#ps-group-ps-ach-auth div.ps-contract-body h6,
#ps-group-ps-ach-auth div.ps-contract-body p,
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#ps-group-ps-ach-auth div.ps-contract-body ol,
#ps-group-ps-ach-auth div.ps-contract-body li,
#ps-group-ps-ach-auth div.ps-contract-body table {
position: relative;
margin-top: 10px;
margin-bottom: 10px;
outline: 0;
}
#ps-group-ps-ach-auth div.ps-contract-body .ps-section {
position: relative;
margin-top: 10px;
margin-bottom: 10px;
outline: 0;
}
#ps-group-ps-ach-auth div.ps-contract-body .ps-section:first-of-type {
margin-top: 0;
}
#ps-group-ps-ach-auth div.ps-contract-body .ps-section[data-section-type="1"] {
font-size: 14px;
}
#ps-group-ps-ach-auth div.ps-contract-body .ps-section[data-section-type="2"] {
font-weight: normal;
}
#ps-group-ps-ach-auth div.ps-contract-body .ps-section[data-section-style="1"] {
font-size: 32px;
}
#ps-group-ps-ach-auth div.ps-contract-body .ps-section[data-section-style="2"] {
font-size: 28px;
}
#ps-group-ps-ach-auth div.ps-contract-body .ps-section[data-section-style="3"] {
font-size: 24px;
}
#ps-group-ps-ach-auth div.ps-contract-body .ps-section[data-section-style="4"] {
font-size: 20px;
}
#ps-group-ps-ach-auth div.ps-contract-body .ps-section[data-section-style="5"] {
font-size: 18px;
}
#ps-group-ps-ach-auth div.ps-contract-body .ps-section[data-section-style="6"] {
font-size: 16px;
}
#ps-group-ps-ach-auth div.ps-contract-body .ps-section[data-section-type="3"] {
font-size: 14px;
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<div id="ps-contract-189201" class="ps-contract" data-cid="189201" data-vid="62cc78f520372145153b0627" data-mjvid="62cc78f520372145153b0627" style="display: block;" data-agreed="false">
<div class="ps-contract-title">ACH Authorization</div>
<div class="ps-contract-options">
<table class="ps-contract-options-links">
<tbody>
<tr>
<td class="ps-contract-options-left">
<div class="ps-expand-button" style="display: none;">Expand Contract</div>
</td>
<td class="ps-contract-options-right">
<a href="https://vault.pactsafe.io/s/ce60a635-12e1-480c-b5b9-d2678cd6b018/contracts/189201.pdf" target="_blank" rel="noopener" class="ps-download-link" onclick="window.open('https://vault.pactsafe.io/s/ce60a635-12e1-480c-b5b9-d2678cd6b018/contracts/189201.pdf')">Download</a>
</td>
</tr>
</tbody>
</table>
</div>
<div class="ps-contract-body ps-contract-full">
<div data-section-type="1" class="ps-section" data-id="ryOuyRGi9" data-time="1657098096496"><span style="background-color: initial;" cursorposition="890">I hereby authorize this company to debit my bank account through the
electronic Automated Clearing House (ACH) network within one to three business days from the payment date for the amount or payment plan amount listed above. I am aware that in the event this company is unable to secure
funds from my bank account for this transaction for any reason, including but not limited to insufficient funds in my account or insufficient or inaccurate information I provided when I submitted the electronic payment,
further collection action may be undertaken by this company, including the application of returned check fees to the extent permitted by law. If my bank returns the payment, I am still responsible for making a payment to
this company. If this is a recurring schedule, I understand this will remain in effect until a written request is submitted to this company requesting a change.</span></div>
</div>
<label for="ps-contract-checkbox-189201" class="ps-checkbox-container ps-checkbox-clickable required">
<input type="checkbox" class="ps-contract-target ps-checkbox required" id="ps-contract-checkbox-189201" name="ps-contract-checkbox-189201" value="189201:62cc78f520372145153b0627">
<div class="ps-contract-label">I acknowledge that I have read, understand and agree to the full terms and conditions set forth above.</div>
</label>
</div>
</div>
<p></p>
<input class="hidden" id="xPactsafeAuthIp" name="xPactsafeAuthIp" value="">
<input class="hidden" id="xPactsafeAuthTimestamp" name="xPactsafeAuthTimestamp" value="">
<input class="hidden" id="xPactsafeUserId" name="xPactsafeUserId" value="ps00017838">
<br>
</div>
</div>
<input type="hidden" id="convenienceFee" value="True">
<input type="hidden" id="ccDollar" value="0">
<input type="hidden" id="achDollar" value="0">
<input type="hidden" id="ccPercent" value="0.03">
<input type="hidden" id="achPercent" value="0">
<input type="hidden" id="customFieldForDescription" value="xCustom09">
<input type="hidden" id="customFieldForOrgAmount" value="xCustom10">
<input type="hidden" id="ExcludeConvFeeNote" value=" If you would like to help defray the cost of processing your payment, click this box and a convenience fee will be automatically added to your payment. Thank You.">
<div style="clear:both;"></div>
<div id="subTotalMain" style="margin-left: 120px;" class="hidden">Sub Total: <span class="currency">$</span><span id="subTotal">0.00</span></div>
<div id="convFeeMain" style="margin-left: 30px;" class="hidden">Electronic Transfer Fee: <span class="currency">$</span><span id="convFee">0.00</span></div>
<div id="amountMain" class="amountMain" style="margin-top: 0px; margin-left: 150px;">
<span class="totalLbl" id="totalLbl">Total:</span> <span id="totalCur">$</span><span id="totalAmount">0.00</span>
</div>
<input id="formS" type="submit" class="formSub" value="Process Payment">
</div>
</div>
<div class="module border module-meter">
<div class="header"> Required Field Meter™ <span class="highlight_req floatright" data-org-text="»Highlight fields" data-sec-text="»Undo highlight fields">»Highlight fields</span>
</div>
<div class="required_empty hidden"></div>
<div class="required_meter group">
<div class="meter">
<div class="bar" style="width: 0%; overflow: hidden;">
<span class="color"></span>
<span class="line"></span>
</div>
<span class="part per100"></span>
<span class="part per90"></span>
<span class="part per80"></span>
<span class="part per70"></span>
<span class="part per60"></span>
<span class="part per50"></span>
<span class="part per40"></span>
<span class="part per30"></span>
<span class="part per20"></span>
<span class="part per10"></span>
<div class="top" style="left: 0%;">
<span class="raised" id="perc_done">0</span>%
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<input type="hidden" name="node" value="21125">
<input type="hidden" name="path" value="/egps">
</form>Text Content
Secure Payment Form Billing Information Name Street City State ALAKAZARCACOCTDCDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPRRISCSDTNTXUTVTVAWAWVWIWY Zip Phone Email Transaction Details Plan Name Invoice Number Invoice cannot exceed 190 characters Custom 09 Custom 10 Amount $ Payment Information Payment Type Credit Card Check Card Number Change Card Number Expiration 01 02 03 04 05 06 07 08 09 10 11 12 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 CVV i Account Type Select One Checking Savings Name on Account Routing Number i Re-enter Routing Number Account Number i Re-enter Account Number Change Acount Info ACH Authorization Expand Contract Download I hereby authorize this company to debit my bank account through the electronic Automated Clearing House (ACH) network within one to three business days from the payment date for the amount or payment plan amount listed above. I am aware that in the event this company is unable to secure funds from my bank account for this transaction for any reason, including but not limited to insufficient funds in my account or insufficient or inaccurate information I provided when I submitted the electronic payment, further collection action may be undertaken by this company, including the application of returned check fees to the extent permitted by law. If my bank returns the payment, I am still responsible for making a payment to this company. If this is a recurring schedule, I understand this will remain in effect until a written request is submitted to this company requesting a change. I acknowledge that I have read, understand and agree to the full terms and conditions set forth above. Sub Total: $0.00 Electronic Transfer Fee: $0.00 Total: $0.00 Required Field Meter™ »Highlight fields 0% X © Copyright 2023 Cardknox (1.04.2307.1263)