payments.chillit.com.au Open in urlscan Pro
35.213.213.120  Public Scan

Form analysis
1 forms found in the DOM

POST ?

<form action="?" method="POST" id="paymentForm">
  <!-- Step 1: Billing Information -->
  <div class="form-group">
    <label for="companyInput"> Company Name: <span style="color:red">*</span></label>
    <div style="display: flex; align-items: center; border: 1px solid #ccc; padding: 5px;">
      <input type="text" id="companyInput" name="company_name" class="form-control" placeholder="Enter company name." style="border:none;">
    </div>
    <span id="errorMessage" style="color:red; font-size:12px;"></span>
  </div>
  <div class="form-group">
    <label for="emailInput">Email Address <span style="color:red">*</span></label>
    <div style="display: flex; align-items: center; border: 1px solid #ccc; padding: 5px;">
      <input type="email" id="emailInput" name="company_email" class="form-control" placeholder="Enter email address." style="border:none;" required="">
    </div>
    <span id="errorMessage1" style="color:red; font-size:12px;"></span>
  </div>
  <div class="form-group">
    <label for="phoneInput">Phone Number <span style="color:red">*</span></label>
    <div style="display: flex; align-items: center; border: 1px solid #ccc; padding: 5px;">
      <input type="tel" id="phoneInput" name="company_phone" class="form-control" placeholder="Enter phone number." style="border:none;" required="">
    </div>
    <span id="errorMessage2" style="color:red; font-size:12px;"></span>
  </div>
  <div class="form-row">
    <div class="form-group col-md-6">
      <label for="paymentAmount">Amount In (dollars): <span style="color:red">*</span></label>
      <div style="display: flex; align-items: center; border: 1px solid #ccc; padding: 5px;">
        <span>$</span>
        <input type="text" id="paymentAmount" name="company_amount" class="form-control" style="border: none;" required="">
      </div>
      <span id="errorMessage3" style="color:red; font-size:12px;"></span>
    </div>
    <div class="form-group col-md-6">
      <label for="invoiceRef">Invoice.Ref <span style="color:red">*</span></label>
      <div style="display: flex; align-items: center; border: 1px solid #ccc; padding: 5px;">
        <input type="text" id="invoiceRef" name="company_invoice" class="form-control" placeholder="Reference No." style="border:none;" required="">
      </div>
      <span id="errorMessage4" style="color:red; font-size:12px;"></span>
    </div>
  </div>
  <!-- Step 2: Payment Type -->
  <div class="form-row">
    <div class="form-group col-md-6">
      <h5 class="mb-3">Payment Type <span style="color:red">*</span></h5>
      <span id="errorMessage5" style="color:red; font-size:12px;"></span>
      <div class="form-check">
        <input class="form-check-input" type="radio" name="card_type" id="mastercard" value="mastercard" disabled="">
        <label class="form-check-label" for="mastercard"> Mastercard (1.12%) </label>
      </div>
      <div class="form-check">
        <input class="form-check-input" type="radio" name="card_type" id="visa" value="visa" disabled="">
        <label class="form-check-label" for="visa"> Visa (1.12%) </label>
      </div>
      <div class="form-check">
        <input class="form-check-input" type="radio" name="card_type" id="amex" value="amex" disabled="">
        <label class="form-check-label" for="amex"> American Express (1.38%) </label>
      </div>
    </div>
    <div class="form-group col-md-12>">
      <div class="row form-inline">
        <div class="col-md-6">
          <label for="subtotal" style="text-align:left;"> Subtotal: </label>
        </div>
        <div class="col-md-6">
          <input type="text" size="10" style="background-color:#ffffff; border:none; color:green; text-align:right;" id="subtotal" class="form-control" readonly="">
        </div>
      </div>
      <div class="row form-inline">
        <div class="col-md-6">
          <label for="subtotal" style="text-align:right;"> Surcharge: </label>
        </div>
        <div class="col-md-6">
          <input type="text" size="10" style="background-color:#ffffff; border:none; color:green; text-align:right" id="surcharge" class="form-control" readonly="">
        </div>
      </div>
      <div class="row horizontal-line"></div>
      <div class="row form-inline">
        <div class="col-md-6">
          <label for="subtotal" style="text-align:right;"> Amount: </label>
        </div>
        <div class="col-md-6">
          <input type="text" size="10" style="background-color:#ffffff; border:none; color:green; text-align:right" id="total" class="form-control invisible-input" readonly="">
        </div>
      </div>
    </div>
  </div>
  <!-- Display amount in cents -->
  <div> <input type="hidden" id="amountInCents"></div>
  <hr>
  <!-- eWAY Pay Now button script -->
  <div class="form-check row mt-3" style="width: 100px;">
    <script src="https://secure.ewaypayments.com/scripts/eCrypt.js" class="eway-paynow-button" data-publicapikey="epk-1A37502D-1452-4BD9-B291-171B4FFB37F3" data-amount="0" data-currency="AUD" data-phone="" data-email="" data-invoiceref=""
      data-invocedescription="" data-buttoncolor="#00263D" data-resulturl="https://payments.chillit.com.au/success/">
    </script><button class="eway-button" style="background: rgb(0, 38, 61);"><span style="display: block; min-height: 30px; background: rgb(0, 38, 61);">Pay Now ($0.00)</span></button>
  </div>
</form>

Text Content

ChillIT

Payment Form

PAYMENT INFORMATION

Company Name: *

Email Address *

Phone Number *

Amount In (dollars): *
$
Invoice.Ref *


PAYMENT TYPE *

Mastercard (1.12%)
Visa (1.12%)
American Express (1.38%)
Subtotal:

Surcharge:


Amount:



--------------------------------------------------------------------------------

Pay Now ($0.00)


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