{"id":4030,"date":"2025-05-06T01:57:32","date_gmt":"2025-05-06T05:57:32","guid":{"rendered":"https:\/\/sei.radixmedia.dev\/?page_id=4030"},"modified":"2025-05-31T01:38:15","modified_gmt":"2025-05-31T05:38:15","slug":"aaa-test-payment-form","status":"publish","type":"page","link":"https:\/\/sei.radixmedia.dev\/index.php\/aaa-test-payment-form\/","title":{"rendered":"AAA &#8211; TEST &#8211; Payment form"},"content":{"rendered":"<p>[moneris_checkout_form]<\/p><form method=\"post\" class=\"moneris-checkout-form\">\n    <div class=\"form-row full\"><label>Policy Number *<\/label><input type=\"text\" name=\"policy_number\" required><small>Please do not include any - characters.<\/small><\/div>\n    <div class=\"form-row full\"><label>Invoice Number *<\/label><input type=\"text\" name=\"invoice_number\" required><small>If you do not have an invoice number, please write \u2018None\u2019 in the field above.<\/small><\/div>\n    <div class=\"form-row full\"><label>Amount to Pay *<\/label><input type=\"text\" name=\"amount\" required><small>Enter a dollar amount with or without cents. For example, to pay $1,000.00, you may enter 1000 or 1000.00<\/small><\/div>\n\n    <div class=\"form-row half\"><label>Email *<\/label><input type=\"email\" name=\"email\" required><\/div>\n    <div class=\"form-row half\"><label>Phone Number *<\/label><input type=\"text\" name=\"phone\" required><\/div>\n\n    <div class=\"form-row half\"><label>First Name<\/label><input type=\"text\" name=\"first_name\" required><\/div>\n    <div class=\"form-row half\"><label>Last Name<\/label><input type=\"text\" name=\"last_name\" required><\/div>\n\n    <div class=\"form-row full\"><label>Company Name\/Account Number *<\/label><input type=\"text\" name=\"company\" required><\/div>\n\n    <div class=\"form-row half\"><label>Address *<\/label><input type=\"text\" name=\"address\" required><\/div>\n    <div class=\"form-row half\"><label>Postal Code *<\/label><input type=\"text\" name=\"postal_code\" required><\/div>\n\n    <div class=\"form-row half\"><label>City *<\/label><input type=\"text\" name=\"city\" required><\/div>\n    <div class=\"form-row half\"><label>Province *<\/label><input type=\"text\" name=\"province\" required><\/div>\n\n    <fieldset class=\"card-box\">\n        <legend>Credit Card Information<\/legend>\n        <div class=\"form-row full\"><label>Credit Card Number *<\/label><input type=\"text\" name=\"cc_number\" required><\/div>\n        <div class=\"form-row full\"><label>Name on Card *<\/label><input type=\"text\" name=\"cc_name\" required><\/div>\n        <div class=\"form-row third\"><label>Month *<\/label>\n            <select name=\"cc_exp_month\" required><option value='1'>1<\/option><option value='2'>2<\/option><option value='3'>3<\/option><option value='4'>4<\/option><option value='5'>5<\/option><option value='6'>6<\/option><option value='7'>7<\/option><option value='8'>8<\/option><option value='9'>9<\/option><option value='10'>10<\/option><option value='11'>11<\/option><option value='12'>12<\/option><\/select>\n        <\/div>\n        <div class=\"form-row third\"><label>Year *<\/label>\n            <select name=\"cc_exp_year\" required><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><\/select>\n        <\/div>\n        <div class=\"form-row third\"><label>CVD Code *<\/label><input type=\"text\" name=\"cc_cvd\" required><\/div>\n        <div class=\"logos\"><img decoding=\"async\" src=\"https:\/\/i.imgur.com\/OKsS0jq.png\" alt=\"Visa Mastercard Logos\" height=\"30\"><\/div>\n    <\/fieldset>\n\n    <input type=\"hidden\" name=\"recaptcha_token\" id=\"recaptcha_token\">\n    <input type=\"hidden\" name=\"seafirst_checkout\" value=\"1\">\n    <button type=\"submit\" class=\"submit-button\">CONTINUE<\/button>\n<\/form>\n\n<script src=\"https:\/\/www.google.com\/recaptcha\/api.js?render=6Ldo_FArAAAAAE2-WzC83AWFZ24shrpdO5XQc2DZ\"><\/script>\n<script>\ngrecaptcha.ready(function() {\n    grecaptcha.execute('6Ldo_FArAAAAAE2-WzC83AWFZ24shrpdO5XQc2DZ', {action: 'submit'}).then(function(token) {\n        document.getElementById('recaptcha_token').value = token;\n    });\n});\n<\/script>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-4030","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/sei.radixmedia.dev\/index.php\/wp-json\/wp\/v2\/pages\/4030"}],"collection":[{"href":"https:\/\/sei.radixmedia.dev\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/sei.radixmedia.dev\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/sei.radixmedia.dev\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/sei.radixmedia.dev\/index.php\/wp-json\/wp\/v2\/comments?post=4030"}],"version-history":[{"count":4,"href":"https:\/\/sei.radixmedia.dev\/index.php\/wp-json\/wp\/v2\/pages\/4030\/revisions"}],"predecessor-version":[{"id":4039,"href":"https:\/\/sei.radixmedia.dev\/index.php\/wp-json\/wp\/v2\/pages\/4030\/revisions\/4039"}],"wp:attachment":[{"href":"https:\/\/sei.radixmedia.dev\/index.php\/wp-json\/wp\/v2\/media?parent=4030"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}