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<form id="client_form" action="" method="POST">
  <div class="template_caption"><b>Betalingsverzoek van Vitaz</b></div>
  <br>
  <div class="template_content">
    <table class="content_table">
      <tbody>
        <tr id="row_status">
          <td><b>Status:</b></td>
          <td class="td_right">Onbetaald</td>
        </tr>
        <tr id="row_name">
          <td><b>Naam:</b></td>
          <td class="td_right">DE BOCK DANIËL MAURICE&nbsp;</td>
        </tr>
        <tr id="row_beneficiary">
          <td><b>Naam ontvanger:</b></td>
          <td class="td_right">Vitaz</td>
        </tr>
        <tr id="row_concerning">
          <td><b>Inzake:</b></td>
          <td class="td_right">Factuur ambulante zorg 2240204989&nbsp;</td>
        </tr>
        <tr id="row_duedate">
          <td><b>Vervaldatum:</b></td>
          <td class="td_right">08-09-2022</td>
        </tr>
        <tr id="row_amount">
          <td><b>Bedrag:</b></td>
          <td class="td_right">€ 3,00</td>
        </tr>
      </tbody>
    </table>
    <br>
    <table class="content_table">
      <tbody>
        <tr>
          <td style="padding-top:7px;" class="td-ideal"><b>Kies uw bank:</b><br><br><img src="/defaultimages/pp_ideal.png" height="45" width="125" border="0"></td>
          <td class="td_right">
            <select class="dropbox" name="IssuerID">
              <option value="0000" selected="selected">Kies uw bank</option>
              <option value="ABNANL2A">ABN AMRO</option>
              <option value="ASNBNL21">ASN Bank</option>
              <option value="BUNQNL2A">bunq</option>
              <option value="HANDNL2A">Handelsbanken</option>
              <option value="INGBNL2A">ING</option>
              <option value="KNABNL2H">Knab</option>
              <option value="RABONL2U">Rabobank</option>
              <option value="RBRBNL21">RegioBank</option>
              <option value="REVOLT21">Revolut</option>
              <option value="SNSBNL2A">SNS</option>
              <option value="TRIONL2U">Triodos Bank</option>
              <option value="FVLBNL22">Van Lanschot</option>
              <option value="0000">Overige banken</option>
            </select><br><br>
            <button class="button" type="submit" name="submit" value="Betaal met iDEAL">Betaal met iDEAL</button>
          </td>
        </tr>
      </tbody>
    </table>
    <br>
    <table class="content_table">
      <tbody>
        <tr>
          <td class="td-mistercash"><img src="/defaultimages/pp_mistercash.png" height="45" width="125" border="0"></td>
          <td class="td_right"><button class="button" type="submit" name="submit" value="Betaal met Bancontact">Betaal met Bancontact</button></td>
        </tr>
      </tbody>
    </table>
    <br>
    <table class="content_table">
      <tbody>
        <tr>
          <td style="padding-top:7px;" class="td-creditcard"><img src="/defaultimages/pp_creditcard.png" height="45" width="125" border="0"></td>
          <td class="td_right">
            <select autocomplete="off" class="dropbox" id="ccv_cc_company" name="cc_company">
              <option value="mastercard">MasterCard</option>
              <option value="visa">Visa</option>
            </select><br><br>
            <button class="button" type="submit" name="submit" value="Betaal met creditcard">Betaal met creditcard</button>
          </td>
        </tr>
      </tbody>
    </table>
  </div>
</form>

Text Content

Nederlands English

Betalingsverzoek van Vitaz


Status:Onbetaald Naam:DE BOCK DANIËL MAURICE  Naam ontvanger:Vitaz
Inzake:Factuur ambulante zorg 2240204989  Vervaldatum:08-09-2022 Bedrag:€ 3,00


Kies uw bank:

Kies uw bank ABN AMRO ASN Bank bunq Handelsbanken ING Knab Rabobank RegioBank
Revolut SNS Triodos Bank Van Lanschot Overige banken

Betaal met iDEAL


Betaal met Bancontact


MasterCard Visa

Betaal met creditcard






© Copyright 2022 Vitaz
NI