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URL: https://govservices.dcra.dc.gov/newoplalicenses/Payments/Payment?id=ecbef4a8-e24f-40e8-b77b-b101efe48c03
Submission: On October 21 via manual from AU — Scanned from DE

Form analysis 1 forms found in the DOM

Name: payForm — 

<form name="payForm" autocomplete="off" novalidate="">
  <div class="card">
    <div class="card-header bg-primary text-white">
      <strong>PAYMENT</strong>
    </div>
    <div class="card-body">
      <input type="hidden" id="hdnLicenseId" value="ecbef4a8-e24f-40e8-b77b-b101efe48c03">
      <input type="hidden" id="hdnEmailAddress" value="ben.paiste@ros.com">
      <input type="hidden" id="hdnLicenseType" value="Security Officer">
      <div class="row">
        <div class="col-sm-6">
          <div class="col-sm-12">
            <div class="form-group" id="divTransactionAmount">
              <label class="control-label" id="lblTransactionAmount">Total Fee: </label> <strong>$99.00</strong>
            </div>
          </div>
        </div>
      </div>
      <div class="row">
        <div class="col-sm-6">
          <div class="col-sm-12">
            <label class="control-label"><i class="fa fa-credit-card"></i> ACCEPTED CARDS</label><br>
            <i class="fa fa-cc-visa fa-2x"></i>&nbsp;<i class="fa fa-cc-discover fa-2x"></i>&nbsp;<i class="fa fa-cc-mastercard fa-2x"></i>&nbsp;<i class="fa fa-cc-amex fa-2x"></i>
          </div><br>
          <div class="col-sm-12">
            <div class="form-group" show-errors="">
              <div class="input-group">
                <input class="form-control" oninput="No(this)" onkeyup="RequiredValidation(this)" onblur="RequiredValidation(this)" type="text" maxlength="16" id="cc_num" name="ccno" placeholder="Card Number">
                <div class="input-group-append"><span class="input-group-text" id="cardType"><b></b></span></div>
              </div>
            </div>
          </div>
          <div class="col-sm-12">
            <div class="form-group" show-errors="">
              <input class="form-control" oninput="exp(this)" onkeyup="RequiredValidation(this)" onblur="RequiredValidation(this)" maxlength="5" type="text" id="cc_exp_date" name="expdate" placeholder="Expiration Date (MM/YY)">
            </div>
          </div>
          <div class="col-sm-12">
            <div class="form-group" show-errors="">
              <div class="input-group">
                <input class="form-control cardCVV" id="cc_cvvCode" name="password" oninput="No(this)" maxlength="4" type="password" placeholder="Security Code">
              </div>
            </div>
          </div>
          <div class="col-sm-12">
            <div class="form-group">
              <input class="form-control" type="text" id="cc_fullname" onkeyup="RequiredValidation(this)" onblur="RequiredValidation(this)" name="ccfullname" placeholder="Name on the card" maxlength="250" capitalize="">
            </div>
          </div>
        </div>
        <div class="col-sm-6" id="vertical-left" style="margin-top: 3.18rem;">
          <div class="col-sm-12">
            <label class="control-label"><i class="fa fa-map-marker"></i> BILLING ADDRESS</label><br>
          </div>
          <div class="col-sm-12">
            <div class="form-group" show-errors="">
              <input type="text" class="form-control" onkeyup="RequiredValidation(this)" onblur="RequiredValidation(this)" id="cc_address" name="ccAddress" placeholder="Street Address" maxlength="250" capitalize="">
            </div>
          </div>
          <div class="col-sm-12">
            <div class="form-group" show-errors="">
              <input type="text" class="form-control" onkeyup="RequiredValidation(this)" onblur="RequiredValidation(this)" id="cc_city" name="ccCity" placeholder="City" maxlength="250" capitalize="">
            </div>
          </div>
          <div class="col-sm-12">
            <div class="form-group" show-errors="">
              <select name="ccstate" onblur="RequiredValidation(this)" class="form-control" id="cc_states">
                <option value="">Select State</option>
                <option value="Alabama">Alabama</option>
                <option value="Alaska">Alaska</option>
                <option value="Arizona">Arizona</option>
                <option value="Arkansas">Arkansas</option>
                <option value="California">California</option>
                <option value="Colorado">Colorado</option>
                <option value="Connecticut">Connecticut</option>
                <option value="Delaware">Delaware</option>
                <option value="District of Columbia">District of Columbia</option>
                <option value="Florida">Florida</option>
                <option value="Georgia">Georgia</option>
                <option value="Hawaii">Hawaii</option>
                <option value="Idaho">Idaho</option>
                <option value="Illinois">Illinois</option>
                <option value="Indiana">Indiana</option>
                <option value="Iowa">Iowa</option>
                <option value="Kansas">Kansas</option>
                <option value="Kentucky">Kentucky</option>
                <option value="Louisiana">Louisiana</option>
                <option value="Maine">Maine</option>
                <option value="Maryland">Maryland</option>
                <option value="Massachusetts">Massachusetts</option>
                <option value="Michigan">Michigan</option>
                <option value="Minnesota">Minnesota</option>
                <option value="Mississippi">Mississippi</option>
                <option value="Missouri">Missouri</option>
                <option value="Montana">Montana</option>
                <option value="Nebraska">Nebraska</option>
                <option value="Nevada">Nevada</option>
                <option value="New Hampshire">New Hampshire</option>
                <option value="New Jersey">New Jersey</option>
                <option value="New Mexico">New Mexico</option>
                <option value="New York">New York</option>
                <option value="North Carolina">North Carolina</option>
                <option value="North Dakota">North Dakota</option>
                <option value="Ohio">Ohio</option>
                <option value="Oklahoma">Oklahoma</option>
                <option value="Oregon">Oregon</option>
                <option value="Pennsylvania">Pennsylvania</option>
                <option value="Puerto Rico">Puerto Rico</option>
                <option value="Rhode Island">Rhode Island</option>
                <option value="South Carolina">South Carolina</option>
                <option value="South Dakota">South Dakota</option>
                <option value="Tennessee">Tennessee</option>
                <option value="Texas">Texas</option>
                <option value="Utah">Utah</option>
                <option value="Vermont">Vermont</option>
                <option value="Virginia">Virginia</option>
                <option value="Washington">Washington</option>
                <option value="West Virginia">West Virginia</option>
                <option value="Wisconsin">Wisconsin</option>
                <option value="Wyoming">Wyoming</option>
              </select>
            </div>
          </div>
          <div class="col-sm-12">
            <div class="form-group" show-errors="">
              <input type="text" class="form-control" onkeyup="RequiredValidation(this)" onblur="RequiredValidation(this)" id="cc_zip" name="ccZip" placeholder="Zip Code" oninput="zip(this)" pattern="/^\d{5}$/" maxlength="5">
            </div>
          </div>
        </div>
      </div>
      <div class="row button-wrapper">
        <div class="col-sm-4">
          <button type="button" onclick="Submit()" class="btn btn-success btn-block pull-right">Next <i class="fa fa-chevron-circle-right"></i></button>
        </div>
      </div>
      <br>
      <div class="row">
        <div class="col-sm-12" id="certLang">
          <p class="float-sm-right">*This site has a <i class="fa fa-lock"></i><a id="verisignLink" target="_blank" href="https://www.digicert.com/"> DigiCert Secure Site Certificate</a>.</p>
        </div>
      </div>
    </div>
  </div>
</form>

Text Content

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New License Form Details

Licensee Name Ben Paiste License Id ecbef4a8-e24f-40e8-b77b-b101efe48c03

PAYMENT
Total Fee: $99.00
ACCEPTED CARDS
   





BILLING ADDRESS



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