Payments

<script src=”https://cdn.jotfor.ms/static/prototype.forms.js” type=”text/javascript”></script> <script src=”https://cdn.jotfor.ms/static/jotform.forms.js?3.3.22697″ type=”text/javascript”></script> <script src=”https://js.squareup.com/v2/paymentform” type=”text/javascript”></script> <script src=”https://cdn.jotfor.ms/js/square.js?v=3.3.22697″ type=”text/javascript”></script> <script type=”text/javascript”> JotForm.init(function(){ if (window.JotForm && JotForm.accessible) $(‘input_13’).setAttribute(‘tabindex’,0); if (window.JotForm && JotForm.accessible) $(‘input_14’).setAttribute(‘tabindex’,0); JotForm.calendarMonths = [“January”,”February”,”March”,”April”,”May”,”June”,”July”,”August”,”September”,”October”,”November”,”December”]; JotForm.calendarDays = [“Sunday”,”Monday”,”Tuesday”,”Wednesday”,”Thursday”,”Friday”,”Saturday”,”Sunday”]; JotForm.calendarOther = {“today”:”Today”}; var languageOptions = document.querySelectorAll(‘#langList li’); for(var langIndex = 0; langIndex < languageOptions.length; langIndex++) { languageOptions[langIndex].on(‘click’, function(e) { setTimeout(function(){ JotForm.setCalendar(“9”, false, {“days”:{“monday”:true,”tuesday”:true,”wednesday”:true,”thursday”:true,”friday”:true,”saturday”:true,”sunday”:true},”future”:true,”past”:true,”custom”:false,”ranges”:false,”start”:””,”end”:””}); }, 0); }); } JotForm.setCalendar(“9”, false, {“days”:{“monday”:true,”tuesday”:true,”wednesday”:true,”thursday”:true,”friday”:true,”saturday”:true,”sunday”:true},”future”:true,”past”:true,”custom”:false,”ranges”:false,”start”:””,”end”:””}); productID = {“0″:”input_12_1001”}; paymentType = “product”; JotForm.setCurrencyFormat(‘USD’,true, ‘point’); JotForm.totalCounter({“input_12_1001”:{“price”:”208″}}); $$(‘.form-product-custom_quantity’).each(function(el, i){el.observe(‘blur’, function(){isNaN(this.value) || this.value < 1 ? this.value = ‘0’ : this.value = parseInt(this.value)})}); $$(‘.form-product-custom_quantity’).each(function(el, i){el.observe(‘focus’, function(){this.value == 0 ? this.value = ” : this.value})}); JotForm.handleProductLightbox(); JotForm.newDefaultTheme = false; JotForm.extendsNewTheme = false; JotForm.newPaymentUIForNewCreatedForms = false; JotForm.alterTexts(undefined); JotForm.alterTexts({“couponApply”:”Apply”,”couponBlank”:”Please enter a coupon.”,”couponChange”:””,”couponEnter”:”Enter coupon”,”couponExpired”:”Coupon is expired. Please try another one.”,”couponInvalid”:”Coupon is invalid.”,”couponValid”:”Coupon is valid.”,”shippingShipping”:”Shipping”,”taxTax”:”Tax”,”totalSubtotal”:”Subtotal”,”totalTotal”:”Total”}, true); JotForm.clearFieldOnHide=”disable”; JotForm.submitError=”jumpToFirstError”; /*INIT-END*/ }); JotForm.prepareCalculationsOnTheFly([null,{“name”:”invoicePayment”,”qid”:”1″,”text”:”Invoice Payment”,”type”:”control_head”},{“name”:”submit2″,”qid”:”2″,”text”:”Submit”,”type”:”control_button”},null,null,{“name”:”name”,”qid”:”5″,”text”:”Name”,”type”:”control_fullname”},null,null,null,{“name”:”date”,”qid”:”9″,”text”:”Date”,”type”:”control_datetime”},null,{“name”:”address”,”qid”:”11″,”text”:”Address”,”type”:”control_address”},{“description”:””,”name”:”myProducts”,”qid”:”12″,”text”:””,”type”:”control_square”},{“description”:””,”name”:”invoiceNumber”,”qid”:”13″,”subLabel”:”Please add your invoice number”,”text”:”Invoice Number”,”type”:”control_textbox”},{“description”:””,”name”:”invoiceAmount”,”qid”:”14″,”subLabel”:”please add your invoice amount”,”text”:”Invoice Amount “,”type”:”control_textbox”}]); setTimeout(function() { JotForm.paymentExtrasOnTheFly([null,{“name”:”invoicePayment”,”qid”:”1″,”text”:”Invoice Payment”,”type”:”control_head”},{“name”:”submit2″,”qid”:”2″,”text”:”Submit”,”type”:”control_button”},null,null,{“name”:”name”,”qid”:”5″,”text”:”Name”,”type”:”control_fullname”},null,null,null,{“name”:”date”,”qid”:”9″,”text”:”Date”,”type”:”control_datetime”},null,{“name”:”address”,”qid”:”11″,”text”:”Address”,”type”:”control_address”},{“description”:””,”name”:”myProducts”,”qid”:”12″,”text”:””,”type”:”control_square”},{“description”:””,”name”:”invoiceNumber”,”qid”:”13″,”subLabel”:”Please add your invoice number”,”text”:”Invoice Number”,”type”:”control_textbox”},{“description”:””,”name”:”invoiceAmount”,”qid”:”14″,”subLabel”:”please add your invoice amount”,”text”:”Invoice Amount “,”type”:”control_textbox”}]);}, 20); </script> <link href=”https://cdn.jotfor.ms/static/formCss.css?3.3.22697″ rel=”stylesheet” type=”text/css” /> <link type=”text/css” rel=”stylesheet” href=”https://cdn.jotfor.ms/css/styles/nova.css?3.3.22697″ /> <link type=”text/css” media=”print” rel=”stylesheet” href=”https://cdn.jotfor.ms/css/printForm.css?3.3.22697″ /> <link type=”text/css” rel=”stylesheet” href=”https://cdn.jotfor.ms/themes/CSS/566a91c2977cdfcd478b4567.css?”/> <link type=”text/css” rel=”stylesheet” href=”https://cdn.jotfor.ms/css/styles/payment/payment_feature.css?3.3.22697″ /> <style type=”text/css”> .form-label-left{ width:150px; } .form-line{ padding-top:12px; padding-bottom:12px; } .form-label-right{ width:150px; } .form-all{ width:690px; color:#555 !important; font-family:”Lucida Grande”, “Lucida Sans Unicode”, “Lucida Sans”, Verdana, sans-serif; font-size:14px; } </style> <style type=”text/css” id=”form-designer-style”> /* Injected CSS Code */ /*PREFERENCES STYLE*/ 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height: 140px; position: absolute; background-size: 256px 140px; background-repeat: no-repeat; width: 100%; } .form-all { margin-top: 150px !important; } .form-all:before { top: -150px; left: 0; background-position: top left; } .ie-8 .form-all:before { display: none; } .ie-8 { margin-top: auto; margin-top: initial; } /*PREFERENCES STYLE*//*__INSPECT_SEPERATOR__*/.supernova .form-all, .form-all { border: 1px solid #080808; box-shadow: 0 3px 20px #333; } .form-label.form-label-auto { display: block; float: none; text-align: left; width: 100%; } /* Injected CSS Code */ </style> <form class=”jotform-form” action=”https://submit.jotform.com/submit/210135747592154/” method=”post” name=”form_210135747592154″ id=”210135747592154″ accept-charset=”utf-8″ autocomplete=”on”> <input type=”hidden” name=”formID” value=”210135747592154″ /> <input type=”hidden” id=”JWTContainer” value=”” /> <input type=”hidden” id=”cardinalOrderNumber” value=”” /> <div role=”main” class=”form-all”> <ul class=”form-section page-section”> <li id=”cid_1″ class=”form-input-wide” data-type=”control_head”> <div class=”form-header-group header-default”> <div class=”header-text httac htvam”> <h2 id=”header_1″ class=”form-header” data-component=”header”> Invoice Payment </h2> </div> </div> </li> <li class=”form-line jf-required” data-type=”control_fullname” id=”id_5″> <label class=”form-label form-label-top form-label-auto” id=”label_5″ for=”first_5″> Name <span class=”form-required”> * </span> </label> <div id=”cid_5″ class=”form-input-wide jf-required”> <div data-wrapper-react=”true”> <span class=”form-sub-label-container” style=”vertical-align:top” data-input-type=”first”> <input type=”text” id=”first_5″ name=”q5_name[first]” class=”form-textbox validate[required]” size=”10″ value=”” data-component=”first” aria-labelledby=”label_5 sublabel_5_first” required=”” /> <label class=”form-sub-label” for=”first_5″ id=”sublabel_5_first” style=”min-height:13px” aria-hidden=”false”> First Name </label> </span> <span class=”form-sub-label-container” style=”vertical-align:top” data-input-type=”last”> <input type=”text” id=”last_5″ name=”q5_name[last]” class=”form-textbox validate[required]” size=”15″ value=”” data-component=”last” aria-labelledby=”label_5 sublabel_5_last” required=”” /> <label class=”form-sub-label” for=”last_5″ id=”sublabel_5_last” style=”min-height:13px” aria-hidden=”false”> Last Name </label> </span> </div> </div> </li> <li class=”form-line jf-required” data-type=”control_textbox” id=”id_13″> <label class=”form-label form-label-top form-label-auto” id=”label_13″ for=”input_13″> Invoice Number <span class=”form-required”> * </span> </label> <div id=”cid_13″ class=”form-input-wide jf-required”> <span class=”form-sub-label-container” style=”vertical-align:top”> <input type=”text” id=”input_13″ name=”q13_invoiceNumber” data-type=”input-textbox” class=”form-textbox validate[required]” size=”20″ value=”” data-component=”textbox” aria-labelledby=”label_13 sublabel_input_13″ required=”” /> <label class=”form-sub-label” for=”input_13″ id=”sublabel_input_13″ style=”min-height:13px” aria-hidden=”false”> Please add your invoice number </label> </span> </div> </li> <li class=”form-line jf-required” data-type=”control_textbox” id=”id_14″> <label class=”form-label form-label-top form-label-auto” id=”label_14″ for=”input_14″> Invoice Amount <span class=”form-required”> * </span> </label> <div id=”cid_14″ class=”form-input-wide jf-required”> <span class=”form-sub-label-container” style=”vertical-align:top”> <input type=”text” id=”input_14″ name=”q14_invoiceAmount” data-type=”input-textbox” class=”form-textbox validate[required]” size=”20″ value=”” data-component=”textbox” aria-labelledby=”label_14 sublabel_input_14″ required=”” /> <label class=”form-sub-label” for=”input_14″ id=”sublabel_input_14″ style=”min-height:13px” aria-hidden=”false”> please add your invoice amount </label> </span> </div> </li> <li class=”form-line jf-required” data-type=”control_address” id=”id_11″> <label class=”form-label form-label-top form-label-auto” id=”label_11″ for=”input_11_addr_line1″> Address <span class=”form-required”> * </span> </label> <div id=”cid_11″ class=”form-input-wide jf-required”> <div summary=”” class=”form-address-table jsTest-addressField”> <div class=”form-address-line-wrapper jsTest-address-line-wrapperField”> <span class=”form-address-line form-address-street-line jsTest-address-lineField”> <span class=”form-sub-label-container” style=”vertical-align:top”> <input type=”text” id=”input_11_addr_line1″ name=”q11_address[addr_line1]” class=”form-textbox validate[required] form-address-line” value=”” data-component=”address_line_1″ aria-labelledby=”label_11 sublabel_11_addr_line1″ /> <label class=”form-sub-label” for=”input_11_addr_line1″ id=”sublabel_11_addr_line1″ style=”min-height:13px” aria-hidden=”false”> Street Address </label> </span> </span> </div> <div class=”form-address-line-wrapper jsTest-address-line-wrapperField”> <span class=”form-address-line form-address-street-line jsTest-address-lineField”> <span class=”form-sub-label-container” style=”vertical-align:top”> <input type=”text” id=”input_11_addr_line2″ name=”q11_address[addr_line2]” class=”form-textbox form-address-line” value=”” data-component=”address_line_2″ aria-labelledby=”label_11 sublabel_11_addr_line2″ /> <label class=”form-sub-label” for=”input_11_addr_line2″ id=”sublabel_11_addr_line2″ style=”min-height:13px” aria-hidden=”false”> Street Address Line 2 </label> </span> </span> </div> <div class=”form-address-line-wrapper jsTest-address-line-wrapperField”> <span class=”form-address-line form-address-city-line jsTest-address-lineField “> <span class=”form-sub-label-container” style=”vertical-align:top”> <input type=”text” id=”input_11_city” name=”q11_address[city]” class=”form-textbox validate[required] form-address-city” value=”” data-component=”city” aria-labelledby=”label_11 sublabel_11_city” /> <label class=”form-sub-label” for=”input_11_city” id=”sublabel_11_city” style=”min-height:13px” aria-hidden=”false”> City </label> </span> </span> <span class=”form-address-line form-address-state-line jsTest-address-lineField “> <span class=”form-sub-label-container” style=”vertical-align:top”> <input type=”text” id=”input_11_state” name=”q11_address[state]” class=”form-textbox validate[required] form-address-state” value=”” data-component=”state” aria-labelledby=”label_11 sublabel_11_state” /> <label class=”form-sub-label” for=”input_11_state” id=”sublabel_11_state” style=”min-height:13px” aria-hidden=”false”> State / Province </label> </span> </span> </div> <div class=”form-address-line-wrapper jsTest-address-line-wrapperField”> <span class=”form-address-line form-address-zip-line jsTest-address-lineField “> <span class=”form-sub-label-container” style=”vertical-align:top”> <input type=”text” id=”input_11_postal” name=”q11_address[postal]” class=”form-textbox form-address-postal” value=”” data-component=”zip” aria-labelledby=”label_11 sublabel_11_postal” /> <label class=”form-sub-label” for=”input_11_postal” id=”sublabel_11_postal” style=”min-height:13px” aria-hidden=”false”> Postal / Zip Code </label> </span> </span> </div> </div> </div> </li> <li class=”form-line” data-type=”control_datetime” id=”id_9″> <label class=”form-label form-label-top form-label-auto” id=”label_9″ for=”lite_mode_9″> Date </label> <div id=”cid_9″ class=”form-input-wide”> <div data-wrapper-react=”true”> <div style=”display:none”> <span class=”form-sub-label-container” style=”vertical-align:top”> <input type=”tel” class=”form-textbox validate[limitDate]” id=”month_9″ name=”q9_date[month]” size=”2″ data-maxlength=”2″ data-age=”” maxLength=”2″ value=”” autoComplete=”off” aria-labelledby=”label_9 sublabel_9_month” /> <span class=”date-separate” aria-hidden=”true”> – </span> <label class=”form-sub-label” for=”month_9″ id=”sublabel_9_month” style=”min-height:13px” aria-hidden=”false”> Month </label> </span> <span class=”form-sub-label-container” style=”vertical-align:top”> <input type=”tel” class=”form-textbox validate[limitDate]” id=”day_9″ name=”q9_date[day]” size=”2″ data-maxlength=”2″ data-age=”” maxLength=”2″ value=”” autoComplete=”off” aria-labelledby=”label_9 sublabel_9_day” /> <span class=”date-separate” aria-hidden=”true”> – </span> <label class=”form-sub-label” for=”day_9″ id=”sublabel_9_day” style=”min-height:13px” aria-hidden=”false”> Day </label> </span> <span class=”form-sub-label-container” style=”vertical-align:top”> <input type=”tel” class=”form-textbox validate[limitDate]” id=”year_9″ name=”q9_date[year]” size=”4″ data-maxlength=”4″ data-age=”” maxLength=”4″ value=”” autoComplete=”off” aria-labelledby=”label_9 sublabel_9_year” /> <label class=”form-sub-label” for=”year_9″ id=”sublabel_9_year” style=”min-height:13px” aria-hidden=”false”> Year </label> </span> </div> <span class=”form-sub-label-container” style=”vertical-align:top”> <input type=”text” class=”form-textbox validate[limitDate, validateLiteDate]” id=”lite_mode_9″ size=”12″ data-maxlength=”12″ maxLength=”12″ data-age=”” value=”” data-format=”mmddyyyy” data-seperator=”-” placeholder=”mm-dd-yyyy” autoComplete=”off” aria-labelledby=”label_9 sublabel_9_litemode” /> <img class=” newDefaultTheme-dateIcon icon-liteMode” alt=”Pick a Date” id=”input_9_pick” src=”https://cdn.jotfor.ms/images/calendar.png” data-component=”datetime” aria-hidden=”true” data-allow-time=”No” data-version=”v1″ /> <label class=”form-sub-label” for=”lite_mode_9″ id=”sublabel_9_litemode” style=”min-height:13px” aria-hidden=”false”> Date </label> </span> </div> </div> </li> <li class=”form-line” data-type=”control_square” id=”id_12″ data-payment=”true”> <label class=”form-label form-label-top form-label-auto” id=”label_12″ for=”input_12″> </label> <div id=”cid_12″ class=”form-input-wide”> <div data-wrapper-react=”true” class=”square-payment-wrapper” data-square-currency=”USD”> <div data-wrapper-react=”true”> <div class=”filter-container”> </div> <input type=”hidden” name=”simple_fpc” data-payment_type=”square” data-component=”payment1″ value=”12″ /> <input type=”hidden” name=”payment_total_checksum” id=”payment_total_checksum” data-component=”payment2″ /> <div id=”image-overlay” class=”overlay-content” style=”display:none”> <img id=”current-image” /> <span class=”lb-prev-button”> prev </span> <span class=”lb-next-button”> next </span> <span class=”lb-close-button”> ( X ) </span> <span class=”image-overlay-product-container”> <ul class=”form-overlay-item” hasicon=”false” hasimages=”false” iconvalue=””> </ul> </span> </div> <div data-wrapper-react=”true”> <span class=”form-product-item hover-product-item ” categories=”non-categorized” pid=”1001″> <div data-wrapper-react=”true” class=”form-product-item-detail”> <input type=”checkbox” class=”form-checkbox form-product-input” id=”input_12_1001″ name=”q12_myProducts[][id]” value=”1001″ checked=”” /> <label for=”input_12_1001″ class=”form-product-container”> <span data-wrapper-react=”true”> <span class=”form-product-name” id=”product-name-input_12_1001″> Consultation Fee </span> <span class=”form-product-details”> <b> <span data-wrapper-react=”true”> $ <span id=”input_12_1001_price”> 208.00 </span> </span> </b> </span> </span> <div class=”form-product-description” id=”product-name-description-input_12_1001″> </div> </label> </div> </span> <br/> <span class=”form-payment-total”> <b> <span id=”total-text”> Total </span> <span class=”form-payment-price”> <span data-wrapper-react=”true”> $ <span id=”payment_total”> 0.00 </span> </span> </span> </b> </span> </div> <hr/> </div> <table class=”form-address-table payment-form-table” style=”border:0″ cellPadding=”0″ cellSpacing=”0″> <tbody> <tr> <th colSpan=”2″ style=”text-align:left;margin-top:20px;display:table” id=”ccTitle12″> Credit Card </th> </tr> <tr> <td width=”50%”> <span class=”form-sub-label-container” style=”vertical-align:top”> <input type=”text” id=”input_12_cc_firstName” name=”q12_myProducts[cc_firstName]” class=”form-textbox cc_firstName” size=”20″ value=”” data-component=”cc_firstName” /> <label class=”form-sub-label” for=”input_12_cc_firstName” id=”sublabel_cc_firstName” style=”min-height:13px;margin:0 0 3px 0″ aria-hidden=”false”> First Name </label> </span> </td> <td width=”50%”> <span class=”form-sub-label-container” style=”vertical-align:top”> <input type=”text” id=”input_12_cc_lastName” name=”q12_myProducts[cc_lastName]” class=”form-textbox cc_lastName” size=”20″ value=”” data-component=”cc_lastName” /> <label class=”form-sub-label” for=”input_12_cc_lastName” id=”sublabel_cc_lastName” style=”min-height:13px;margin:0 0 3px 0″ aria-hidden=”false”> Last Name </label> </span> </td> </tr> <tr class=”if_cc_field”> <td width=”50%”> <input id=”square_dummy” style=”display:none” data-sandbox=”false” /> <span class=”form-sub-label-container” style=”vertical-align:top”> <div id=”square_cc_number” class=”square-hosted-fields” style=”width:147px”> </div> <label class=”form-sub-label” for=”square_cc_number” id=”sublabel_cc_number” style=”min-height:13px;margin:0 0 3px 0″ aria-hidden=”false”> Credit Card Number </label> </span> </td> <td width=”50%”> <span class=”form-sub-label-container” style=”vertical-align:top”> <div id=”square_cc_ccv” class=”square-hosted-fields” style=”width:120px”> </div> <label class=”form-sub-label” for=”square_cc_ccv” id=”sublabel_cc_ccv” style=”min-height:13px;margin:0 0 3px 0″ aria-hidden=”false”> Security Code </label> </span> </td> </tr> <tr> <td width=”50%”> <span class=”form-sub-label-container” style=”vertical-align:top”> <div id=”square_cc_exp” class=”square-hosted-fields” style=”width:147px”> </div> <label class=”form-sub-label” for=”square_cc_exp” id=”sublabel_cc_exp” style=”min-height:13px;margin:0 0 3px 0″ aria-hidden=”false”> Expiration Date </label> </span> </td> <td width=”50%”> <span class=”form-sub-label-container” style=”vertical-align:top”> <div id=”square_cc_postal” class=”square-hosted-fields” style=”width:120px”> </div> <label class=”form-sub-label” for=”square_cc_postal” id=”sublabel_cc_postal” style=”min-height:13px;margin:0 0 3px 0″ aria-hidden=”false”> Postal Code </label> </span> </td> </tr> </tbody> </table> </div> </div> </li> <li class=”form-line” data-type=”control_button” id=”id_2″> <div id=”cid_2″ class=”form-input-wide”> <div style=”margin-left:156px” data-align=”auto” class=”form-buttons-wrapper form-buttons-auto jsTest-button-wrapperField”> <button id=”input_2″ type=”submit” class=”form-submit-button submit-button jf-form-buttons jsTest-submitField” data-component=”button” data-content=””> Submit </button> </div> </div> </li> <li style=”display:none”> Should be Empty: <input type=”text” name=”website” value=”” /> </li> </ul> </div> <script> JotForm.showJotFormPowered = “0”; </script> <script> JotForm.poweredByText = “Powered by JotForm”; </script> <input type=”hidden” 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