Client Number (normally hidden)
Mode (normally hidden)
direct_post_
Session ID (normally hidden)
Collection Amount
input "type=radio name=formOfPayment id=formOfPayment value=CreditCard / Pay by Credit Card
Card Number
Expiry Date
Month
January
February
March
April
May
June
July
August
September
October
November
December
Month
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
Security Code
input "type"=radio name=formOfPayment id=formOfPayment value=ACH / Pay by ACH
Routing Number
Account Number
Pay using Net Terms
input "type=radio name=formOfPayment id=formOfPayment value=Net0 / Pay using Net 0
input "type=radio name=formOfPayment id=formOfPayment value=Net10 / Pay using Net 10
input "type=radio name=formOfPayment id=formOfPayment value=Net15 / Pay using Net 15
input "type=radio name=formOfPayment id=formOfPayment value=Net30 / Pay using Net 30
input "type=radio name=formOfPayment id=formOfPayment value=Net45 / Pay using Net 45
input "type=radio name=formOfPayment id=formOfPayment value=Net60 / Pay using Net 60