payments.avalara.com
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34.212.54.187
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URL:
https://payments.avalara.com/assisted-sales?reference_number=4c1083ab-318c-4178-9a47-dd5e8fd0e69d
Submission: On June 13 via manual from IN — Scanned from DE
Submission: On June 13 via manual from IN — Scanned from DE
Form analysis
1 forms found in the DOMPOST https://secureacceptance.cybersource.com/embedded/token/create
<form aria-label="Payment Form" id="payment_form" method="post" novalidate="novalidate" action="https://secureacceptance.cybersource.com/embedded/token/create" target="cybersouce-page"><input type="hidden" id="access_key" name="access_key"
value="95177318db6135bb908d0c7147377172"><input type="hidden" id="profile_id" name="profile_id" value="9C839277-81DE-418F-87EE-6FBFE5ED79B4"><input type="hidden" id="transaction_uuid" name="transaction_uuid"
value="1c97beba-fb18-48d8-9f66-8df10b1c9ab8"><input type="hidden" id="signed_field_names" name="signed_field_names"
value="access_key,profile_id,transaction_uuid,signed_field_names,unsigned_field_names,signed_date_time,locale,transaction_type,reference_number,amount,currency,echeck_sec_code"><input type="hidden" id="unsigned_field_names"
name="unsigned_field_names" value=""><input type="hidden" id="signed_date_time" name="signed_date_time" value="2023-06-13T21:09:14Z"><input type="hidden" id="transaction_type" name="transaction_type" value="create_payment_token"><input
type="hidden" id="locale" name="locale" value="en"><input type="hidden" id="currency" name="currency" value="USD"><input type="hidden" id="amount" name="amount" value="0.00"><input type="hidden" id="reference_number" name="reference_number"
value="4c1083ab-318c-4178-9a47-dd5e8fd0e69d"><input type="hidden" id="signature" name="signature" value="9CJWV50dH3W3y2yKMFBHzCRFjTlE/7qJHKjn6fSoM2U="><input type="hidden" id="echeck_sec_code" name="echeck_sec_code" value="WEB">
<div id="achSection" style="display: none;"><s-row><s-col span="2"></s-col><s-col span="8">
<h3>Billing Information</h3>
<hr><s-row><s-col span="auto"><label class="required" for="first_name">First Name</label><input type="text" id="first_name" name="first_name" aria-required="true"></s-col><s-col span="auto"><label class="required" for="last_name">Last
Name</label><input type="text" id="last_name" name="last_name" aria-required="true"></s-col></s-row><s-row><s-col span="auto"><label for="company_name">Company Name</label><input type="text" id="company_name"
name="company_name"></s-col></s-row><s-row><s-col span="auto"><label class="required" for="address_1">Address Line 1</label><input type="text" id="address_1" name="address_1" aria-required="true"></s-col><s-col span="auto"><label
for="address_2">Address Line 2</label><input type="text" id="address_2" name="address_2"></s-col></s-row><s-row><s-col span="6"><label class="required" for="country">Country/Region</label><select id="country" name="country" required="">
<option value="" hidden="">Select...</option>
</select></s-col></s-row><s-row> <s-col span="6"><label class="required" for="city">City</label><input type="text" id="city" name="city" aria-required="true"></s-col><s-col span="auto"><label class="required" for="state"
id="stateLabel">Region</label><select id="state" name="state" required="">
<option value="" hidden="">Select...</option>
</select></s-col><s-col span="auto"><label class="required" for="postal_code">ZIP/Postal Code</label><input type="text" id="postal_code" name="postal_code" aria-required="true"></s-col></s-row><s-row><s-col span="auto"><label
for="phone_number">Phone Number</label><input type="text" id="phone_number" name="phone_number"></s-col><s-col span="auto"><label for="email">Email</label><input type="text" id="email" name="email"></s-col></s-row><s-row><s-col
span="auto">
<h3>Payment Details</h3>
<hr>
</s-col></s-row><s-row> <s-col span="auto"><label class="required" for="ach_account">Account Number</label><input type="text" id="ach_account" name="ach_account" aria-required="true"></s-col><s-col span="auto"><label class="required"
for="ach_account_confirm">Confirm Account Number</label><input type="text" id="ach_account_confirm" name="ach_account_confirm" aria-required="true"></s-col></s-row><s-row> <s-col span="auto"><label class="required"
for="ach_routing">Routing Number</label><input type="text" id="ach_routing" name="ach_routing" aria-required="true"></s-col><s-col span="auto"><label class="required" for="ach_account_type">Account Type</label><select
id="ach_account_type" name="ach_account_type">
<option selected="" value="Checking">Checking</option>
<option value="Savings">Savings</option>
</select></s-col></s-row><s-row><s-col span="auto">
<p>For customers providing banking information, Customer shall confirm payment authorization with its financial institution for eCheck and ACH transactions by supplying Avalara's originator ID, 1911718107, to the financial institution.
This ensures that the financial institution recognizes Avalara transactions as authorized so they are processed timely.</p>
</s-col></s-row><button class="primary loading" type="submit" id="submit" name="submit">Submit</button>
</s-col></s-row></div>
<div id="ccSection"><iframe id="cybersource-page" name="cybersouce-page" title="Credit Card Fields"></iframe></div>
</form>
Text Content
Secure Payment Acceptance Sign in PLEASE PROVIDE THE PAYMENT INFORMATION THAT WILL BE USED FOR THE ORDER: -------------------------------------------------------------------------------- Never Board Entertainment BILLING INFORMATION -------------------------------------------------------------------------------- First NameLast NameCompany NameAddress Line 1Address Line 2Country/RegionSelect... CityRegionSelect...ZIP/Postal CodePhone NumberEmail PAYMENT DETAILS -------------------------------------------------------------------------------- Account NumberConfirm Account Number Routing NumberAccount TypeCheckingSavings For customers providing banking information, Customer shall confirm payment authorization with its financial institution for eCheck and ACH transactions by supplying Avalara's originator ID, 1911718107, to the financial institution. This ensures that the financial institution recognizes Avalara transactions as authorized so they are processed timely. Submit Avalara.com Contact Terms Privacy © Avalara, Inc. Contact Help Center Avalara University Submit a support case