premierbiotech.com
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Submitted URL: http://premierbiotech.com/payonline/PaymentOnlineByInvoiceCode?invoiceId=4000130&orderCode=F4B81D5EC
Effective URL: https://premierbiotech.com/payonline/PaymentOnlineByInvoiceCode?invoiceId=4000130&orderCode=F4B81D5EC
Submission: On January 12 via manual from US — Scanned from DE
Effective URL: https://premierbiotech.com/payonline/PaymentOnlineByInvoiceCode?invoiceId=4000130&orderCode=F4B81D5EC
Submission: On January 12 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST /PayOnline/OrderDetails
<form action="/PayOnline/OrderDetails" id="payonline_form" method="post" novalidate="novalidate"><input id="OrderId" name="OrderId" type="hidden" value="406984"><input id="StatementCode" name="StatementCode" type="hidden" value="F4B81D5EC"><input
id="OrderGuid" name="OrderGuid" type="hidden" value="30a8cef0-bd70-4e6b-81a8-9407c39704e7"><input data-val="true" data-val-required="The Statement # field is required." id="StatementId" name="StatementId" type="hidden" value="406984"><input
id="StatementGuid" name="StatementGuid" type="hidden" value="30a8cef0-bd70-4e6b-81a8-9407c39704e7">
<div class="container payonline-container">
<div class="row">
<div class="col-md-12 background-white padding-bottom-3 text-left">
<div class="row text-left">
<div class="col-md-12 payment-header">
<div class="payment-logo">
<img class="pb-logo" src="/images/New-Logo.jpg" alt="Premier Biotech" border="0">
</div>
<div class="payment-address"> Premier Biotech, Inc. <br> 723 Kasota Avenue SE <br> Minneapolis, MN 55414 </div>
<div class="payment-heading">
<span class="heading-dkblue-20">Premier Biotech Billing</span>
</div>
</div>
</div>
<div class="row payment-details-container">
<div class="row">
<div class="col-md-12">
<div class="validation-summary-valid" data-valmsg-summary="true">
<ul>
<li style="display:none"></li>
</ul>
</div>
</div>
</div>
<div class="col-md-12">
<div class="row">
<div class="col-md-3">
<label allowhtmlattribute="True" for="OrderId" title="">Order #</label>: <br>
<label allowhtmlattribute="True" for="OrderDate" title="">Order Date</label>: <br>
<label>Order Total:</label><br>
<label>Amount Due:</label><br><br>
<label>Payment Amount:</label>
</div>
<div class="col-md-3">
<label class="not-bold">406984 </label> <br>
<label class="not-bold">12/19/2022</label> <br>
<label class="not-bold">$3,276.00</label> <br>
<label class="not-bold">$3,276.00</label> <br>
<input class="amount-text currency" id="PaymentAmount" name="PaymentAmount" style="width: 105px" type="text" value="3,276.00">
<span class="field-validation-valid" data-valmsg-for="PaymentAmount" data-valmsg-replace="true"></span><br>
</div>
</div>
<script type="text/javascript">
</script>
<div class="row padding-top-3">
<div class="col-md-6">
<span class="heading-black-17">Billing Address</span>
</div>
</div>
<div class="row">
<div class="col-md-3">
<label>Name:</label>
</div>
<div class="col-md-4">
<div class="row">
<div class="col-md-6">
<input id="StatementPayment_Address_FirstName" name="StatementPayment.Address.FirstName" placeholder="First Name" type="text" value="">
<span class="field-validation-valid" data-valmsg-for="StatementPayment.Address.FirstName" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6">
<input id="StatementPayment_Address_LastName" name="StatementPayment.Address.LastName" placeholder="Last Name" type="text" value="">
<span class="field-validation-valid" data-valmsg-for="StatementPayment.Address.LastName" data-valmsg-replace="true"></span>
</div>
</div>
</div>
</div>
<div class="row padding-top-half">
<div class="col-md-3">
<label>Email:</label>
</div>
<div class="col-md-4">
<input id="StatementPayment_Address_Email" name="StatementPayment.Address.Email" placeholder="Email" type="text" value="">
<span class="field-validation-valid" data-valmsg-for="StatementPayment.Address.Email" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row padding-top-half">
<div class="col-md-3">
<label>Phone Number:</label>
</div>
<div class="col-md-4">
<input id="StatementPayment_Address_PhoneNumber" name="StatementPayment.Address.PhoneNumber" placeholder="Phone Number" type="text" value="">
<span class="field-validation-valid" data-valmsg-for="StatementPayment.Address.PhoneNumber" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row padding-top-half">
<div class="col-md-7">
<input class="addressline1 address-line" id="StatementPayment_Address_Address1" name="StatementPayment.Address.Address1" placeholder="Address Line 1" type="text" value="">
<span class="field-validation-valid" data-valmsg-for="StatementPayment.Address.Address1" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row padding-top-half">
<div class="col-md-6">
<input class="address-line" id="StatementPayment_Address_Address2" name="StatementPayment.Address.Address2" placeholder="Address Line 2" type="text" value="">
<span class="field-validation-valid" data-valmsg-for="StatementPayment.Address.Address2" data-valmsg-replace="true"></span>
</div>
<div class="col-md-6">
<input class="city" id="StatementPayment_Address_City" name="StatementPayment.Address.City" placeholder="City" type="text" value="">
<span class="field-validation-valid" data-valmsg-for="StatementPayment.Address.City" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row padding-top-half">
<div class="col-md-4">
<select class="country" data-val="true" data-val-number="The field Country must be a number." id="StatementPayment_Address_CountryId" name="StatementPayment.Address.CountryId">
<option value="">Country</option>
<option value="0">Select country</option>
<option value="1">United States</option>
<option value="2">Canada</option>
<option value="86">Afghanistan</option>
<option value="87">Albania</option>
<option value="88">Algeria</option>
<option value="89">American Samoa</option>
<option value="90">Andorra</option>
<option value="91">Angola</option>
<option value="92">Anguilla</option>
<option value="93">Antarctica</option>
<option value="94">Antigua and Barbuda</option>
<option value="3">Argentina</option>
<option value="4">Armenia</option>
<option value="5">Aruba</option>
<option value="6">Australia</option>
<option value="7">Austria</option>
<option value="8">Azerbaijan</option>
<option value="9">Bahamas</option>
<option value="95">Bahrain</option>
<option value="10">Bangladesh</option>
<option value="96">Barbados</option>
<option value="11">Belarus</option>
<option value="12">Belgium</option>
<option value="13">Belize</option>
<option value="97">Benin</option>
<option value="14">Bermuda</option>
<option value="98">Bhutan</option>
<option value="15">Bolivia</option>
<option value="16">Bosnia and Herzegowina</option>
<option value="99">Botswana</option>
<option value="100">Bouvet Island</option>
<option value="17">Brazil</option>
<option value="101">British Indian Ocean Territory</option>
<option value="102">Brunei Darussalam</option>
<option value="18">Bulgaria</option>
<option value="103">Burkina Faso</option>
<option value="104">Burundi</option>
<option value="105">Cambodia</option>
<option value="106">Cameroon</option>
<option value="107">Cape Verde</option>
<option value="19">Cayman Islands</option>
<option value="108">Central African Republic</option>
<option value="109">Chad</option>
<option value="20">Chile</option>
<option value="21">China</option>
<option value="110">Christmas Island</option>
<option value="111">Cocos (Keeling) Islands</option>
<option value="22">Colombia</option>
<option value="112">Comoros</option>
<option value="113">Congo</option>
<option value="114">Cook Islands</option>
<option value="23">Costa Rica</option>
<option value="115">Cote D'Ivoire</option>
<option value="24">Croatia (local Name: Hrvatska)</option>
<option value="25">Cuba</option>
<option value="26">Cyprus</option>
<option value="27">Czech Republic</option>
<option value="28">Denmark</option>
<option value="116">Djibouti</option>
<option value="117">Dominica</option>
<option value="29">Dominican Republic</option>
<option value="30">Ecuador</option>
<option value="31">Egypt</option>
<option value="118">El Salvador</option>
<option value="119">Equatorial Guinea</option>
<option value="120">Eritrea</option>
<option value="121">Estonia</option>
<option value="122">Ethiopia</option>
<option value="123">Falkland Islands (Malvinas)</option>
<option value="124">Faroe Islands</option>
<option value="125">Fiji</option>
<option value="32">Finland</option>
<option value="33">France</option>
<option value="126">French Guiana</option>
<option value="127">French Polynesia</option>
<option value="128">French Southern Territories</option>
<option value="129">Gabon</option>
<option value="130">Gambia</option>
<option value="34">Georgia</option>
<option value="35">Germany</option>
<option value="131">Ghana</option>
<option value="36">Gibraltar</option>
<option value="37">Greece</option>
<option value="132">Greenland</option>
<option value="133">Grenada</option>
<option value="134">Guadeloupe</option>
<option value="135">Guam</option>
<option value="38">Guatemala</option>
<option value="136">Guinea</option>
<option value="137">Guinea-bissau</option>
<option value="138">Guyana</option>
<option value="139">Haiti</option>
<option value="140">Heard and Mc Donald Islands</option>
<option value="141">Honduras</option>
<option value="39">Hong Kong</option>
<option value="40">Hungary</option>
<option value="142">Iceland</option>
<option value="41">India</option>
<option value="42">Indonesia</option>
<option value="143">Iran (Islamic Republic of)</option>
<option value="144">Iraq</option>
<option value="43">Ireland</option>
<option value="44">Israel</option>
<option value="45">Italy</option>
<option value="46">Jamaica</option>
<option value="47">Japan</option>
<option value="48">Jordan</option>
<option value="49">Kazakhstan</option>
<option value="145">Kenya</option>
<option value="146">Kiribati</option>
<option value="147">Korea</option>
<option value="50">Korea, Democratic People's Republic of</option>
<option value="51">Kuwait</option>
<option value="148">Kyrgyzstan</option>
<option value="149">Lao People's Democratic Republic</option>
<option value="150">Latvia</option>
<option value="151">Lebanon</option>
<option value="152">Lesotho</option>
<option value="153">Liberia</option>
<option value="154">Libyan Arab Jamahiriya</option>
<option value="155">Liechtenstein</option>
<option value="156">Lithuania</option>
<option value="157">Luxembourg</option>
<option value="158">Macau</option>
<option value="159">Macedonia</option>
<option value="160">Madagascar</option>
<option value="161">Malawi</option>
<option value="52">Malaysia</option>
<option value="162">Maldives</option>
<option value="163">Mali</option>
<option value="164">Malta</option>
<option value="165">Marshall Islands</option>
<option value="166">Martinique</option>
<option value="167">Mauritania</option>
<option value="168">Mauritius</option>
<option value="169">Mayotte</option>
<option value="53">Mexico</option>
<option value="170">Micronesia</option>
<option value="171">Moldova</option>
<option value="172">Monaco</option>
<option value="173">Mongolia</option>
<option value="174">Montserrat</option>
<option value="175">Morocco</option>
<option value="176">Mozambique</option>
<option value="177">Myanmar</option>
<option value="178">Namibia</option>
<option value="179">Nauru</option>
<option value="180">Nepal</option>
<option value="54">Netherlands</option>
<option value="181">Netherlands Antilles</option>
<option value="182">New Caledonia</option>
<option value="55">New Zealand</option>
<option value="183">Nicaragua</option>
<option value="184">Niger</option>
<option value="185">Nigeria</option>
<option value="186">Niue</option>
<option value="187">Norfolk Island</option>
<option value="188">Northern Mariana Islands</option>
<option value="56">Norway</option>
<option value="189">Oman</option>
<option value="57">Pakistan</option>
<option value="190">Palau</option>
<option value="191">Panama</option>
<option value="192">Papua New Guinea</option>
<option value="58">Paraguay</option>
<option value="59">Peru</option>
<option value="60">Philippines</option>
<option value="193">Pitcairn</option>
<option value="61">Poland</option>
<option value="62">Portugal</option>
<option value="63">Puerto Rico</option>
<option value="64">Qatar</option>
<option value="194">Reunion</option>
<option value="65">Romania</option>
<option value="66">Russia</option>
<option value="195">Rwanda</option>
<option value="196">Saint Kitts and Nevis</option>
<option value="197">Saint Lucia</option>
<option value="198">Saint Vincent and the Grenadines</option>
<option value="199">Samoa</option>
<option value="200">San Marino</option>
<option value="201">Sao Tome and Principe</option>
<option value="67">Saudi Arabia</option>
<option value="202">Senegal</option>
<option value="85">Serbia</option>
<option value="203">Seychelles</option>
<option value="204">Sierra Leone</option>
<option value="68">Singapore</option>
<option value="69">Slovakia (Slovak Republic)</option>
<option value="70">Slovenia</option>
<option value="205">Solomon Islands</option>
<option value="206">Somalia</option>
<option value="71">South Africa</option>
<option value="207">South Georgia & South Sandwich Islands</option>
<option value="72">Spain</option>
<option value="208">Sri Lanka</option>
<option value="209">St. Helena</option>
<option value="210">St. Pierre and Miquelon</option>
<option value="211">Sudan</option>
<option value="212">Suriname</option>
<option value="213">Svalbard and Jan Mayen Islands</option>
<option value="214">Swaziland</option>
<option value="73">Sweden</option>
<option value="74">Switzerland</option>
<option value="215">Syrian Arab Republic</option>
<option value="75">Taiwan</option>
<option value="216">Tajikistan</option>
<option value="217">Tanzania</option>
<option value="76">Thailand</option>
<option value="218">Togo</option>
<option value="219">Tokelau</option>
<option value="220">Tonga</option>
<option value="221">Trinidad and Tobago</option>
<option value="222">Tunisia</option>
<option value="77">Turkey</option>
<option value="223">Turkmenistan</option>
<option value="224">Turks and Caicos Islands</option>
<option value="225">Tuvalu</option>
<option value="226">Uganda</option>
<option value="78">Ukraine</option>
<option value="79">United Arab Emirates</option>
<option value="80">United Kingdom</option>
<option value="82">Uruguay</option>
<option value="83">Uzbekistan</option>
<option value="227">Vanuatu</option>
<option value="228">Vatican City State (Holy See)</option>
<option value="84">Venezuela</option>
<option value="229">Viet Nam</option>
<option value="230">Virgin Islands (British)</option>
<option value="231">Virgin Islands (U.S.)</option>
<option value="232">Wallis and Futuna Islands</option>
<option value="233">Western Sahara</option>
<option value="234">Yemen</option>
<option value="235">Zambia</option>
<option value="236">Zimbabwe</option>
</select>
<span class="field-validation-valid" data-valmsg-for="StatementPayment.Address.CountryId" data-valmsg-replace="true"></span>
</div>
<div class="col-md-4">
<select class="state" data-val="true" data-val-number="The field State / province must be a number." id="StateProvinceId" name="StatementPayment.Address.StateProvinceId">
<option value="">State</option>
<option selected="selected" value="0">None</option>
<option value="1">AA (Armed Forces Americas)</option>
<option value="2">AE (Armed Forces Europe)</option>
<option value="3">Alabama</option>
<option value="4">Alaska</option>
<option value="5">American Samoa</option>
<option value="6">AP (Armed Forces Pacific)</option>
<option value="7">Arizona</option>
<option value="8">Arkansas</option>
<option value="9">California</option>
<option value="10">Colorado</option>
<option value="11">Connecticut</option>
<option value="12">Delaware</option>
<option value="13">District of Columbia</option>
<option value="14">Federated States of Micronesia</option>
<option value="15">Florida</option>
<option value="16">Georgia</option>
<option value="17">Guam</option>
<option value="18">Hawaii</option>
<option value="19">Idaho</option>
<option value="20">Illinois</option>
<option value="21">Indiana</option>
<option value="22">Iowa</option>
<option value="23">Kansas</option>
<option value="24">Kentucky</option>
<option value="25">Louisiana</option>
<option value="26">Maine</option>
<option value="27">Marshall Islands</option>
<option value="28">Maryland</option>
<option value="29">Massachusetts</option>
<option value="30">Michigan</option>
<option value="31">Minnesota</option>
<option value="32">Mississippi</option>
<option value="33">Missouri</option>
<option value="34">Montana</option>
<option value="35">Nebraska</option>
<option value="36">Nevada</option>
<option value="37">New Hampshire</option>
<option value="38">New Jersey</option>
<option value="39">New Mexico</option>
<option value="40">New York</option>
<option value="41">North Carolina</option>
<option value="42">North Dakota</option>
<option value="43">Northern Mariana Islands</option>
<option value="44">Ohio</option>
<option value="45">Oklahoma</option>
<option value="46">Oregon</option>
<option value="47">Palau</option>
<option value="48">Pennsylvania</option>
<option value="49">Puerto Rico</option>
<option value="50">Rhode Island</option>
<option value="51">South Carolina</option>
<option value="52">South Dakota</option>
<option value="53">Tennessee</option>
<option value="54">Texas</option>
<option value="55">Utah</option>
<option value="56">Vermont</option>
<option value="57">Virgin Islands</option>
<option value="58">Virginia</option>
<option value="59">Washington</option>
<option value="60">West Virginia</option>
<option value="61">Wisconsin</option>
<option value="62">Wyoming</option>
</select>
<span class="field-validation-valid" data-valmsg-for="StatementPayment.Address.StateProvinceId" data-valmsg-replace="true"></span>
</div>
<div class="col-md-4">
<input class="zip" id="StatementPayment_Address_ZipPostalCode" name="StatementPayment.Address.ZipPostalCode" placeholder="Zip Code" type="text" value="">
<span class="field-validation-valid" data-valmsg-for="StatementPayment.Address.ZipPostalCode" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row padding-top-3">
<div class="col-md-6">
<span class="heading-black-17">Payment Information</span>
</div>
</div>
<div class="row padding-top-half">
<div class="col-md-6">
<label>Select Credit Card</label>
</div>
</div>
<div class="row padding-top-half">
<div class="col-md-6">
<select class="dropdownlists" id="CreditCardType" name="CreditCardType">
<option value="">Card Type</option>
<option value="Visa">Visa</option>
<option value="MasterCard">Master card</option>
<option value="Discover">Discover</option>
<option value="Amex">Amex</option>
</select>
</div>
</div>
<div class="row padding-top-half">
<div class="col-md-6">
<label>Cardholder Name</label>
</div>
</div>
<div class="row padding-top-half">
<div class="col-md-6">
<input autocomplete="off" id="CardholderName" name="CardholderName" placeholder="Cardholder Name" type="text" value="">
<span class="field-validation-valid" data-valmsg-for="CardholderName" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row padding-top-half">
<div class="col-md-6">
<label>Card Number</label>
</div>
</div>
<div class="row padding-top-half">
<div class="col-md-6">
<input autocomplete="off" id="ccNumber" maxlength="22" name="CardNumber" placeholder="Card Number" type="text" value="">
<span class="field-validation-valid" data-valmsg-for="CardNumber" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row padding-top-half">
<div class="col-md-6">
<label>Expiration Date</label>
</div>
</div>
<div class="row padding-top-half">
<div class="col-md-3">
<label>Month:</label><br>
<select id="ExpireMonth" name="ExpireMonth">
<option value="">Month</option>
<option value="1">01</option>
<option value="2">02</option>
<option value="3">03</option>
<option value="4">04</option>
<option value="5">05</option>
<option value="6">06</option>
<option value="7">07</option>
<option value="8">08</option>
<option value="9">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select>
</div>
<div class="col-md-3">
<label>Year:</label><br>
<select id="ExpireYear" name="ExpireYear">
<option value="">Year</option>
<option value="2023">2023</option>
<option value="2024">2024</option>
<option value="2025">2025</option>
<option value="2026">2026</option>
<option value="2027">2027</option>
<option value="2028">2028</option>
<option value="2029">2029</option>
<option value="2030">2030</option>
<option value="2031">2031</option>
<option value="2032">2032</option>
<option value="2033">2033</option>
<option value="2034">2034</option>
<option value="2035">2035</option>
<option value="2036">2036</option>
<option value="2037">2037</option>
</select>
</div>
<div class="col-md-3">
<label>Card Code:</label><br>
<input autocomplete="off" id="ccCSC" maxlength="4" name="CardCode" placeholder="CVV" style="Width: 60px;" type="text" value="">
<span class="field-validation-valid" data-valmsg-for="CardCode" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row padding-top-half">
<div class="col-md-6 col-sm-12">
<div>
</div>
</div>
</div>
<div class="row padding-top-1">
<div class="col-md-3 col-sm-12">
</div>
<div class="col-md-4 col-sm-12">
</div>
<div class="col-md-2 col-sm-12">
</div>
</div>
<div class="row padding-top-1">
<div class="col-md-3 col-sm-6">
<div>
</div>
</div>
<div class="col-md-3 col-sm-6">
<div>
</div>
</div>
</div>
<script type="text/javascript">
$(document).ready(function() {});
</script>
<div class="row padding-top-3 text-center">
<div class="col-md-6 col-md-offset-3">
<button class="submitbutton" type="submit" alt="Submit Payment">Submit Payment</button>
</div>
</div>
<div class="row padding-top-half text-center">
<div class="col-md-6 col-md-offset-3">
<a href="/payonline" class="button-link">Back</a>
</div>
</div>
</div>
</div>
<div class="row padding-top-1">
<div class="col-md-6">
</div>
</div>
<div class="row padding-top-1">
<div class="col-md-6">
</div>
<div class="col-md-6">
</div>
</div>
</div>
</div>
</div>
</form>Text Content
Back to Premier Biotech Need Support? Help Premier Biotech, Inc. 723 Kasota Avenue SE Minneapolis, MN 55414 Premier Biotech Billing * Order #: Order Date: Order Total: Amount Due: Payment Amount: 406984 12/19/2022 $3,276.00 $3,276.00 Billing Address Name: Email: Phone Number: Country Select country United States Canada Afghanistan 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 Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia (local Name: Hrvatska) 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 Guinea Guinea-bissau Guyana Haiti Heard and Mc Donald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Korea, Democratic People's Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia 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 Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia & South Sandwich Islands Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Zambia Zimbabwe State None AA (Armed Forces Americas) AE (Armed Forces Europe) Alabama Alaska American Samoa AP (Armed Forces Pacific) Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands 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 Payment Information Select Credit Card Card Type Visa Master card Discover Amex Cardholder Name Card Number Expiration Date Month: Month 01 02 03 04 05 06 07 08 09 10 11 12 Year: Year 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 Card Code: Submit Payment Back