midlandappliance.megadigitalservices.ca Open in urlscan Pro
173.201.184.42  Public Scan

Form analysis
1 forms found in the DOM

POST ajax.php

<form id="monerisForm" action="ajax.php" enctype="multipart/form-data" method="post">
  <h2 class="title-h2">Make a Payment</h2>
  <input type="hidden" id="retailer" name="retailer" value="midlandappliance">
  <div class="shadow info-card">
    <h3>Payment information</h3>
    <div id="fld_cardholder" class="">
      <label for="cust_id" class="">Customer #</label>
      <input type="text" name="cust_id" class="form-control" id="cust_id" value="" placeholder="" maxlength="50" size="50" autocomplete="off" required="">
    </div>
    <div id="fld_cardholder" class="">
      <label for="invoice_number" class="">Invoice Number</label>
      <input type="text" name="invoice_number" class="form-control" id="invoice_number" value="" placeholder="" maxlength="50" size="50" autocomplete="off" required="">
    </div>
    <div class="row">
      <div class="col-lg-6 chkt_first_name">
        <div id="fld_first_name" class="">
          <label for="payment_amount" class="">Payment Amount</label>
          <span id="payment_amount_sign"><input type="number" name="payment_amount" class="form-control" id="payment_amount" value="" placeholder="0.00" step=".01" min="1" max="50000" size="50" autocomplete="off" required=""></span>
        </div>
      </div>
      <div class="col-lg-6 chkt_last_name">
        <div id="fld_last_name" class="">
          <label for="postal_code" class="">Billing Postal Code</label>
          <input type="text" name="postal_code" class="form-control" id="postal_code" value="" placeholder="" maxlength="7" required="" size="50" pattern="[A-Za-z][0-9][A-Za-z]\s?[0-9][A-Za-z][0-9]">
        </div>
      </div>
    </div>
    <div class="row">
      <div id="g-recaptcha" class="g-recaptcha" data-sitekey="6LeyChQqAAAAAAPWIyrAXbWJeJ0W5uyWy3qwRieA" style="margin-top: 25px; margin-left: 15px;"></div>
      <script src="https://www.google.com/recaptcha/api.js?onload=onloadCallback&amp;render=explicit" async="" defer=""></script>
    </div>
    <div id="total-container" class="row">
      <div class="col-0 col-md-7 col-lg-7 total-row"><a href="https://www.midlandappliance.com/" aria-label="Cancel" id="continue-shopping" class="text-action">Go back to website</a></div>
      <div class="col-12 col-md-5 col-lg-5 total-row"><input type="submit" id="submit" disabled="disabled" class="form-control chkt_btn_primary disabled" value="Proceed to Payment"></div>
    </div>
    <div id="moneris-error" class="row">
    </div>
  </div>
</form>

Text Content

MAKE A PAYMENT


PAYMENT INFORMATION

Customer #
Invoice Number
Payment Amount
Billing Postal Code

Go back to website