wurtec.chargifypay.com Open in urlscan Pro
44.227.111.139  Public Scan

Form analysis
1 forms found in the DOM

POST /update_payment/71534437/51271ea264

<form class="new_subscription" id="hosted-payment-form" data-confirmed="no" action="/update_payment/71534437/51271ea264" accept-charset="UTF-8" method="post"><input name="utf8" type="hidden" value="✓" autocomplete="off"><input type="hidden"
    name="_method" value="put" autocomplete="off"><input type="hidden" name="authenticity_token" value="iTLeXoRN1WN0qYHYyKNNn6EOY7OhkNpjrszVW+9KTduDDwk8aaAV01jGdl9VAPjuXfMLxJs7j4mpsaKo69v7eA==" autocomplete="off">
  <input type="hidden" name="uniqueness_token" id="uniqueness_token" value="b523ab00-d254-013c-eecb-064220a75327" autocomplete="off">
  <input value="credit_card" autocomplete="off" type="hidden" name="subscription[payment_profile_attributes][payment_method]" id="subscription_payment_profile_attributes_payment_method">
  <h2>Billing Information</h2>
  <div class="section_three kaxsdc" data-event="load">
    <input id="payment_type" value="credit_card" autocomplete="off" type="hidden" name="subscription[payment_profile_attributes][payment_type]">
    <div class="row">
      <p class="left">
        <label for="subscription_payment_profile_attributes_first_name"> First Name on Account</label><br>
        <input type="text" value="George" name="subscription[payment_profile_attributes][first_name]" id="subscription_payment_profile_attributes_first_name">
      </p>
      <p class="right">
        <label for="subscription_payment_profile_attributes_last_name"> Last Name on Account</label><br>
        <input type="text" value="Holmstrom" name="subscription[payment_profile_attributes][last_name]" id="subscription_payment_profile_attributes_last_name">
      </p>
    </div>
    <div id="credit_card_info">
      <div class="row">
        <p class="left">
          <label for="subscription_payment_profile_attributes_full_number"> Card Number</label><br>
          <input autocomplete="off" type="text" name="subscription[payment_profile_attributes][full_number]" id="subscription_payment_profile_attributes_full_number"><br>
        </p>
        <div id="credit_card_logos" class="left">
          <img class="visa_logo" alt="Visa" src="https://d2honoqsqjbuho.cloudfront.net/assets/cc/cc_visa-642d099336bb44316abdacb6b49e04708c50fb0602b731e71100dfbfc122f1e5.png"> <img class="mastercard_logo" alt="Mastercard"
            src="https://d2honoqsqjbuho.cloudfront.net/assets/cc/cc_mc-2bb4ec2c935d9597a9b7f1a5d19d04068eb33337de906e3025c4fadbdd30fb26.png"> <img class="amex_logo" alt="Amex"
            src="https://d2honoqsqjbuho.cloudfront.net/assets/cc/cc_amex-012f5a5793d9c4ea6de3496eaa373fb40508574060d7a76ae1b30994f45a7d4e.png"> <img class="discover_logo" alt="Discover"
            src="https://d2honoqsqjbuho.cloudfront.net/assets/cc/cc_discover-4bbd01888a8c1d3c2659ea8b13d4a4501c143c2692d4a71fc7707d30025ac251.png">
        </div>
      </div>
      <div class="row">
        <p class="left current_card"> Current card on file: XXXX-XXXX-XXXX-4338 </p>
      </div>
      <div class="row">
        <p class="left">
          <label for="subscription_payment_profile_attributes_cvv">* CVV</label><br>
          <input autocomplete="off" type="text" name="subscription[payment_profile_attributes][cvv]" id="subscription_payment_profile_attributes_cvv">
        </p>
        <p class="left">
          <label for="subscription_payment_profile_attributes_expiration_month"> Expiration Date</label><br>
          <select id="subscription_payment_profile_attributes_expiration_month" name="subscription[payment_profile_attributes][expiration_month]">
            <option value="" label=" "></option>
            <option value="1">1 - Jan</option>
            <option value="2">2 - Feb</option>
            <option value="3">3 - Mar</option>
            <option value="4" selected="selected">4 - Apr</option>
            <option value="5">5 - May</option>
            <option value="6">6 - Jun</option>
            <option value="7">7 - Jul</option>
            <option value="8">8 - Aug</option>
            <option value="9">9 - Sep</option>
            <option value="10">10 - Oct</option>
            <option value="11">11 - Nov</option>
            <option value="12">12 - Dec</option>
          </select>
          <select id="subscription_payment_profile_attributes_expiration_year" name="subscription[payment_profile_attributes][expiration_year]">
            <option value="" label=" "></option>
            <option value="2024" selected="selected">2024</option>
            <option value="2025">2025</option>
            <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>
            <option value="2037">2037</option>
            <option value="2038">2038</option>
            <option value="2039">2039</option>
            <option value="2040">2040</option>
            <option value="2041">2041</option>
            <option value="2042">2042</option>
            <option value="2043">2043</option>
            <option value="2044">2044</option>
          </select>
        </p>
      </div>
    </div>
    <div id="ach_info" style="display: none;">
      <div class="row">
        <p class="left">
          <label for="subscription_payment_profile_attributes_bank_name"> Bank Name</label><br>
          <input type="text" name="subscription[payment_profile_attributes][bank_name]" id="subscription_payment_profile_attributes_bank_name">
        </p>
        <p class="left margin-left" id="bank_account_holder_type_select">
          <label for="subscription_payment_profile_attributes_bank_account_holder_type"> Account Holder Type</label><br>
          <select name="subscription[payment_profile_attributes][bank_account_holder_type]" id="subscription_payment_profile_attributes_bank_account_holder_type">
            <option value="personal">personal</option>
            <option value="business">business</option>
          </select>
        </p>
      </div>
      <div class="row" <p="" id="bank_account_type_select">
        <label for="subscription_payment_profile_attributes_bank_account_type"> Account Type</label><br>
        <select name="subscription[payment_profile_attributes][bank_account_type]" id="subscription_payment_profile_attributes_bank_account_type">
          <option value="checking">checking</option>
          <option value="savings">savings</option>
        </select>
        <p></p>
      </div>
      <div class="row">
        <p class="left">
          <label for="subscription_payment_profile_attributes_bank_routing_number"> Routing Number</label><br>
          <input type="text" name="subscription[payment_profile_attributes][bank_routing_number]" id="subscription_payment_profile_attributes_bank_routing_number">
        </p>
        <p class="right">
          <label for="subscription_payment_profile_attributes_bank_account_number"> Account Number</label><br>
          <input type="text" name="subscription[payment_profile_attributes][bank_account_number]" id="subscription_payment_profile_attributes_bank_account_number">
        </p>
      </div>
      <div class="row" id="check_example">
        <a rel="check_example_image" id="check_example_link" href="#">Need help finding your routing number or account number?</a>
      </div>
      <div class="row hidden" id="check_example_image">
        <p class="left" style="border: 1px solid #CCC;">
          <img width="450" src="https://d2honoqsqjbuho.cloudfront.net/assets/example-check-ab820b420330f528a3729d71895e1570820ae16f967fd104225b104829db8b8a.png">
        </p>
      </div>
      <input type="hidden" name="direct_debit_ach_scheme" id="direct_debit_ach_scheme" value="true" autocomplete="off">
      <input type="hidden" name="subscription[agreement_terms]" id="ach_agreement_terms" value="">
    </div>
  </div>
  <div id="billing_address">
    <h2>Billing Address:</h2>
    <div class="row">
      <p class="left">
        <label for="subscription_payment_profile_attributes_billing_address">* Address 1</label><br>
        <input class="address billing_address" type="text" value="SC Employment &amp; Workf" name="subscription[payment_profile_attributes][billing_address]" id="subscription_payment_profile_attributes_billing_address">
      </p>
      <p class="right">
        <label for="subscription_payment_profile_attributes_billing_address_2">Address 2</label><br>
        <input class="address billing_address address_2" type="text" value="PO Box 995" name="subscription[payment_profile_attributes][billing_address_2]" id="subscription_payment_profile_attributes_billing_address_2">
      </p>
    </div>
    <div class="row">
      <p class="left">
        <label for="subscription_payment_profile_attributes_billing_country">* Billing Country</label><br>
        <select class="country_select address billing_address" id="subscription_payment_profile_attributes_billing_country" rel="subscription_payment_profile_attributes_billing_state" name="subscription[payment_profile_attributes][billing_country]">
          <option value="" label=" "></option>
          <option selected="selected" value="US">United States</option>
          <option value="GB">United Kingdom</option>
          <option value="CA">Canada</option>
          <option value="NZ">New Zealand</option>
          <option value="AU">Australia</option>
          <option value="ZA">South Africa</option>
          <option value="SG">Singapore</option>
          <option value="--">--</option>
          <option value="--">--</option>
          <option value="AF">Afghanistan</option>
          <option value="AL">Albania</option>
          <option value="DZ">Algeria</option>
          <option value="AS">American Samoa</option>
          <option value="AD">Andorra</option>
          <option value="AO">Angola</option>
          <option value="AI">Anguilla</option>
          <option value="AQ">Antarctica</option>
          <option value="AG">Antigua and Barbuda</option>
          <option value="AR">Argentina</option>
          <option value="AM">Armenia</option>
          <option value="AW">Aruba</option>
          <option value="AU">Australia</option>
          <option value="AT">Austria</option>
          <option value="AZ">Azerbaijan</option>
          <option value="BS">Bahamas</option>
          <option value="BH">Bahrain</option>
          <option value="BD">Bangladesh</option>
          <option value="BB">Barbados</option>
          <option value="BY">Belarus</option>
          <option value="BE">Belgium</option>
          <option value="BZ">Belize</option>
          <option value="BJ">Benin</option>
          <option value="BM">Bermuda</option>
          <option value="BT">Bhutan</option>
          <option value="BO">Bolivia</option>
          <option value="BQ">Bonaire, Sint Eustatius and Saba</option>
          <option value="BA">Bosnia and Herzegovina</option>
          <option value="BW">Botswana</option>
          <option value="BV">Bouvet Island</option>
          <option value="BR">Brazil</option>
          <option value="IO">British Indian Ocean Territory</option>
          <option value="BN">Brunei Darussalam</option>
          <option value="BG">Bulgaria</option>
          <option value="BF">Burkina Faso</option>
          <option value="BI">Burundi</option>
          <option value="KH">Cambodia</option>
          <option value="CM">Cameroon</option>
          <option value="CA">Canada</option>
          <option value="IC">Canary Islands</option>
          <option value="CV">Cape Verde</option>
          <option value="KY">Cayman Islands</option>
          <option value="CF">Central African Republic</option>
          <option value="TD">Chad</option>
          <option value="CL">Chile</option>
          <option value="CN">China</option>
          <option value="CX">Christmas Island</option>
          <option value="CC">Cocos (Keeling) Islands</option>
          <option value="CO">Colombia</option>
          <option value="KM">Comoros</option>
          <option value="CG">Congo</option>
          <option value="CD">Congo, The Democratic Republic Of The</option>
          <option value="CK">Cook Islands</option>
          <option value="CR">Costa Rica</option>
          <option value="HR">Croatia</option>
          <option value="CU">Cuba</option>
          <option value="CW">Curaçao</option>
          <option value="CY">Cyprus</option>
          <option value="CZ">Czech Republic</option>
          <option value="CI">Côte D'Ivoire</option>
          <option value="DK">Denmark</option>
          <option value="DJ">Djibouti</option>
          <option value="DM">Dominica</option>
          <option value="DO">Dominican Republic</option>
          <option value="EC">Ecuador</option>
          <option value="EG">Egypt</option>
          <option value="SV">El Salvador</option>
          <option value="GQ">Equatorial Guinea</option>
          <option value="ER">Eritrea</option>
          <option value="EE">Estonia</option>
          <option value="ET">Ethiopia</option>
          <option value="FK">Falkland Islands (Malvinas)</option>
          <option value="FO">Faroe Islands</option>
          <option value="FJ">Fiji</option>
          <option value="FI">Finland</option>
          <option value="FR">France</option>
          <option value="GF">French Guiana</option>
          <option value="PF">French Polynesia</option>
          <option value="TF">French Southern Territories</option>
          <option value="GA">Gabon</option>
          <option value="GM">Gambia</option>
          <option value="GE">Georgia</option>
          <option value="DE">Germany</option>
          <option value="GH">Ghana</option>
          <option value="GI">Gibraltar</option>
          <option value="GR">Greece</option>
          <option value="GL">Greenland</option>
          <option value="GD">Grenada</option>
          <option value="GP">Guadeloupe</option>
          <option value="GU">Guam</option>
          <option value="GT">Guatemala</option>
          <option value="GG">Guernsey</option>
          <option value="GN">Guinea</option>
          <option value="GW">Guinea-Bissau</option>
          <option value="GY">Guyana</option>
          <option value="HT">Haiti</option>
          <option value="HM">Heard and McDonald Islands</option>
          <option value="VA">Holy See (Vatican City State)</option>
          <option value="HN">Honduras</option>
          <option value="HK">Hong Kong</option>
          <option value="HU">Hungary</option>
          <option value="IS">Iceland</option>
          <option value="IN">India</option>
          <option value="ID">Indonesia</option>
          <option value="IR">Iran, Islamic Republic Of</option>
          <option value="IQ">Iraq</option>
          <option value="IE">Ireland</option>
          <option value="IM">Isle of Man</option>
          <option value="IL">Israel</option>
          <option value="IT">Italy</option>
          <option value="JM">Jamaica</option>
          <option value="JP">Japan</option>
          <option value="JE">Jersey</option>
          <option value="JO">Jordan</option>
          <option value="KZ">Kazakhstan</option>
          <option value="KE">Kenya</option>
          <option value="KI">Kiribati</option>
          <option value="KP">Korea, Democratic People's Republic Of</option>
          <option value="KR">Korea, Republic of</option>
          <option value="KW">Kuwait</option>
          <option value="KG">Kyrgyzstan</option>
          <option value="LA">Lao People's Democratic Republic</option>
          <option value="LV">Latvia</option>
          <option value="LB">Lebanon</option>
          <option value="LS">Lesotho</option>
          <option value="LR">Liberia</option>
          <option value="LY">Libya</option>
          <option value="LI">Liechtenstein</option>
          <option value="LT">Lithuania</option>
          <option value="LU">Luxembourg</option>
          <option value="MO">Macao</option>
          <option value="MK">Macedonia, the Former Yugoslav Republic Of</option>
          <option value="MG">Madagascar</option>
          <option value="MW">Malawi</option>
          <option value="MY">Malaysia</option>
          <option value="MV">Maldives</option>
          <option value="ML">Mali</option>
          <option value="MT">Malta</option>
          <option value="MH">Marshall Islands</option>
          <option value="MQ">Martinique</option>
          <option value="MR">Mauritania</option>
          <option value="MU">Mauritius</option>
          <option value="YT">Mayotte</option>
          <option value="MX">Mexico</option>
          <option value="FM">Micronesia, Federated States Of</option>
          <option value="MD">Moldova, Republic of</option>
          <option value="MC">Monaco</option>
          <option value="MN">Mongolia</option>
          <option value="ME">Montenegro</option>
          <option value="MS">Montserrat</option>
          <option value="MA">Morocco</option>
          <option value="MZ">Mozambique</option>
          <option value="MM">Myanmar</option>
          <option value="NA">Namibia</option>
          <option value="NR">Nauru</option>
          <option value="NP">Nepal</option>
          <option value="NL">Netherlands</option>
          <option value="AN">Netherlands Antilles</option>
          <option value="NC">New Caledonia</option>
          <option value="NZ">New Zealand</option>
          <option value="NI">Nicaragua</option>
          <option value="NE">Niger</option>
          <option value="NG">Nigeria</option>
          <option value="NU">Niue</option>
          <option value="NF">Norfolk Island</option>
          <option value="MP">Northern Mariana Islands</option>
          <option value="NO">Norway</option>
          <option value="OM">Oman</option>
          <option value="PK">Pakistan</option>
          <option value="PW">Palau</option>
          <option value="PS">Palestine, State of</option>
          <option value="PA">Panama</option>
          <option value="PG">Papua New Guinea</option>
          <option value="PY">Paraguay</option>
          <option value="PE">Peru</option>
          <option value="PH">Philippines</option>
          <option value="PN">Pitcairn</option>
          <option value="PL">Poland</option>
          <option value="PT">Portugal</option>
          <option value="PR">Puerto Rico</option>
          <option value="QA">Qatar</option>
          <option value="RO">Romania</option>
          <option value="RU">Russian Federation</option>
          <option value="RW">Rwanda</option>
          <option value="RE">Réunion</option>
          <option value="BL">Saint Barthélemy</option>
          <option value="SH">Saint Helena</option>
          <option value="KN">Saint Kitts And Nevis</option>
          <option value="LC">Saint Lucia</option>
          <option value="MF">Saint Martin</option>
          <option value="PM">Saint Pierre And Miquelon</option>
          <option value="VC">Saint Vincent And The Grenedines</option>
          <option value="WS">Samoa</option>
          <option value="SM">San Marino</option>
          <option value="ST">Sao Tome and Principe</option>
          <option value="SA">Saudi Arabia</option>
          <option value="SN">Senegal</option>
          <option value="RS">Serbia</option>
          <option value="SC">Seychelles</option>
          <option value="SL">Sierra Leone</option>
          <option value="SG">Singapore</option>
          <option value="SX">Sint Maarten</option>
          <option value="SK">Slovakia</option>
          <option value="SI">Slovenia</option>
          <option value="SB">Solomon Islands</option>
          <option value="SO">Somalia</option>
          <option value="ZA">South Africa</option>
          <option value="GS">South Georgia and the South Sandwich Islands</option>
          <option value="SS">South Sudan</option>
          <option value="ES">Spain</option>
          <option value="LK">Sri Lanka</option>
          <option value="SD">Sudan</option>
          <option value="SR">Suriname</option>
          <option value="SJ">Svalbard And Jan Mayen</option>
          <option value="SZ">Swaziland</option>
          <option value="SE">Sweden</option>
          <option value="CH">Switzerland</option>
          <option value="SY">Syrian Arab Republic</option>
          <option value="TW">Taiwan, Republic Of China</option>
          <option value="TJ">Tajikistan</option>
          <option value="TZ">Tanzania, United Republic of</option>
          <option value="TH">Thailand</option>
          <option value="TL">Timor-Leste</option>
          <option value="TG">Togo</option>
          <option value="TK">Tokelau</option>
          <option value="TO">Tonga</option>
          <option value="TT">Trinidad and Tobago</option>
          <option value="TN">Tunisia</option>
          <option value="TR">Turkey</option>
          <option value="TM">Turkmenistan</option>
          <option value="TC">Turks and Caicos Islands</option>
          <option value="TV">Tuvalu</option>
          <option value="UG">Uganda</option>
          <option value="UA">Ukraine</option>
          <option value="AE">United Arab Emirates</option>
          <option value="GB">United Kingdom</option>
          <option selected="selected" value="US">United States</option>
          <option value="UM">United States Minor Outlying Islands</option>
          <option value="UY">Uruguay</option>
          <option value="UZ">Uzbekistan</option>
          <option value="VU">Vanuatu</option>
          <option value="VE">Venezuela, Bolivarian Republic of</option>
          <option value="VN">Vietnam</option>
          <option value="VG">Virgin Islands, British</option>
          <option value="VI">Virgin Islands, U.S.</option>
          <option value="WF">Wallis and Futuna</option>
          <option value="EH">Western Sahara</option>
          <option value="YE">Yemen</option>
          <option value="ZM">Zambia</option>
          <option value="ZW">Zimbabwe</option>
          <option value="AX">Åland Islands</option>
        </select>
      </p>
      <p class="left">
        <label for="subscription_payment_profile_attributes_billing_state">* Billing State</label><br>
        <select class="subdivision_select address billing_address" rel="subscription_payment_profile_attributes_billing_country" data-preselect="SC" name="subscription[payment_profile_attributes][billing_state]"
          id="subscription_payment_profile_attributes_billing_state">
          <option value="">Please select</option>
          <option value="AL">Alabama</option>
          <option value="AK">Alaska</option>
          <option value="AS">American Samoa</option>
          <option value="AZ">Arizona</option>
          <option value="AR">Arkansas</option>
          <option value="AA">Armed Forces Americas</option>
          <option value="AE">Armed Forces Europe</option>
          <option value="AP">Armed Forces Pacific</option>
          <option value="CA">California</option>
          <option value="CO">Colorado</option>
          <option value="CT">Connecticut</option>
          <option value="DE">Delaware</option>
          <option value="DC">District of Columbia</option>
          <option value="FL">Florida</option>
          <option value="GA">Georgia</option>
          <option value="GU">Guam</option>
          <option value="HI">Hawaii</option>
          <option value="ID">Idaho</option>
          <option value="IL">Illinois</option>
          <option value="IN">Indiana</option>
          <option value="IA">Iowa</option>
          <option value="KS">Kansas</option>
          <option value="KY">Kentucky</option>
          <option value="LA">Louisiana</option>
          <option value="ME">Maine</option>
          <option value="MD">Maryland</option>
          <option value="MA">Massachusetts</option>
          <option value="MI">Michigan</option>
          <option value="MN">Minnesota</option>
          <option value="MS">Mississippi</option>
          <option value="MO">Missouri</option>
          <option value="MT">Montana</option>
          <option value="MP">N. Mariana Islands</option>
          <option value="NE">Nebraska</option>
          <option value="NV">Nevada</option>
          <option value="NH">New Hampshire</option>
          <option value="NJ">New Jersey</option>
          <option value="NM">New Mexico</option>
          <option value="NY">New York</option>
          <option value="NC">North Carolina</option>
          <option value="ND">North Dakota</option>
          <option value="OH">Ohio</option>
          <option value="OK">Oklahoma</option>
          <option value="OR">Oregon</option>
          <option value="PA">Pennsylvania</option>
          <option value="PR">Puerto Rico</option>
          <option value="RI">Rhode Island</option>
          <option value="SC">South Carolina</option>
          <option value="SD">South Dakota</option>
          <option value="TN">Tennessee</option>
          <option value="TX">Texas</option>
          <option value="UM">US Minor Outlying Islands</option>
          <option value="UT">Utah</option>
          <option value="VT">Vermont</option>
          <option value="VI">Virgin Islands</option>
          <option value="VA">Virginia</option>
          <option value="WA">Washington</option>
          <option value="WV">West Virginia</option>
          <option value="WI">Wisconsin</option>
          <option value="WY">Wyoming</option>
        </select>
      </p>
    </div>
    <div class="row">
      <p class="left">
        <label for="subscription_payment_profile_attributes_billing_city">* Billing City</label><br>
        <input size="30" class="address billing_address" type="text" value="Columbia" name="subscription[payment_profile_attributes][billing_city]" id="subscription_payment_profile_attributes_billing_city">
      </p>
      <p class="left">
        <label for="subscription_payment_profile_attributes_billing_zip">* Billing ZIP Code</label><br>
        <input class="address billing_address" maxlength="10" size="10" type="text" value="29202-0995" name="subscription[payment_profile_attributes][billing_zip]" id="subscription_payment_profile_attributes_billing_zip">
      </p>
    </div>
  </div>
  <div id="ach_agreement_terms_container" class="section_five" style="display: none;">
    <div id="ach_agreement_terms_text"><b>ACH AUTHORIZATION AGREEMENT</b><br><br>04/01/2024<br><br>By clicking the button below I affirm that I have proper authority and authorize Wurtec, Inc. to charge this bank account owned by SC Department of
      Employment &amp; Workforce or as specified in the form above, starting on 01/24/2025, and every 12 months thereafter, until this subscription is canceled, for the amount of <span id="ach-amount-agreed-to">$720.00</span> for Wur-Link (POTS
      Replacement). If SC Department of Employment &amp; Workforce makes changes to this subscription that affect these terms, this agreement will remain in effect according to the updated terms. <br><br>In the event that an incorrect amount is
      debited from this account, I authorize Wurtec, Inc. to credit this account in order to correct the situation. This payment authorization is valid, in compliance with NACHA regulations, and will remain in effect unless I, or another authorized
      user, notifies Wurtec, Inc. of its cancellation by contacting Wurtec Subscription Services &lt;setup@wurtec.com&gt; or 1-800-837-1066.<br><br>Signed,</div><br>
    <div class="row">
      <p class="left">
        <label for="subscription_authorizer_first_name">* Authorizer First Name</label><br>
        <input type="text" name="subscription[authorizer_first_name]" id="subscription_authorizer_first_name">
      </p>
      <p class="right">
        <label for="subscription_authorizer_last_name">* Authorizer Last Name</label><br>
        <input type="text" name="subscription[authorizer_last_name]" id="subscription_authorizer_last_name">
      </p>
    </div>
  </div>
  <div class="section_last section_footer">
    <ul id="billing_summary">
      <b>Merchant contact info:</b><br> 1-800-837-1066<br> wurtecsales@wurtec.com<br> 6200 Brent Drive, 43611 Toledo, US
    </ul>
  </div>
  <div class="button_wrapper">
    <input type="submit" name="commit" value="Update" id="subscription_submit" data-type="ssp" data-disable-with="Update" style="">
  </div><!-- End of "button_wrapper" -->
</form>

Text Content

This page is secure.


CONNECTED SERVICE: WUR-LINK (POTS REPLACEMENT)





BILLING INFORMATION

First Name on Account


Last Name on Account


Card Number





Current card on file: XXXX-XXXX-XXXX-4338

* CVV


Expiration Date
1 - Jan 2 - Feb 3 - Mar 4 - Apr 5 - May 6 - Jun 7 - Jul 8 - Aug 9 - Sep 10 - Oct
11 - Nov 12 - Dec 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035
2036 2037 2038 2039 2040 2041 2042 2043 2044

Bank Name


Account Holder Type
personal business

Account Type
checking savings



Routing Number


Account Number


Need help finding your routing number or account number?




BILLING ADDRESS:

* Address 1


Address 2


* Billing Country
United States United Kingdom Canada New Zealand Australia South Africa Singapore
-- -- Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla
Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria
Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin
Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina
Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam
Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canary Islands Cape Verde
Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos
(Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Of The
Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Côte D'Ivoire
Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador
Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe
Islands Fiji Finland France French Guiana French Polynesia French Southern
Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland
Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti
Heard and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong
Hungary Iceland India Indonesia Iran, Islamic Republic Of Iraq Ireland Isle of
Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea,
Democratic People's Republic Of Korea, Republic of Kuwait Kyrgyzstan Lao
People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein
Lithuania Luxembourg Macao Macedonia, the Former Yugoslav Republic Of Madagascar
Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania
Mauritius Mayotte Mexico Micronesia, Federated States Of Moldova, Republic of
Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru
Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger
Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau
Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn
Poland Portugal Puerto Rico Qatar Romania Russian Federation Rwanda Réunion
Saint Barthélemy Saint Helena Saint Kitts And Nevis Saint Lucia Saint Martin
Saint Pierre And Miquelon Saint Vincent And The Grenedines Samoa San Marino Sao
Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore
Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South
Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan
Suriname Svalbard And Jan Mayen Swaziland Sweden Switzerland Syrian Arab
Republic Taiwan, Republic Of China Tajikistan Tanzania, United Republic of
Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey
Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates
United Kingdom United States United States Minor Outlying Islands Uruguay
Uzbekistan Vanuatu Venezuela, Bolivarian Republic of Vietnam Virgin Islands,
British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia
Zimbabwe Åland Islands

* Billing State
Please selectAlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces
AmericasArmed Forces EuropeArmed Forces
PacificCaliforniaColoradoConnecticutDelawareDistrict of
ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaN.
Mariana IslandsNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth
CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth
CarolinaSouth DakotaTennesseeTexasUS Minor Outlying IslandsUtahVermontVirgin
IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

* Billing City


* Billing ZIP Code


ACH AUTHORIZATION AGREEMENT

04/01/2024

By clicking the button below I affirm that I have proper authority and authorize
Wurtec, Inc. to charge this bank account owned by SC Department of Employment &
Workforce or as specified in the form above, starting on 01/24/2025, and every
12 months thereafter, until this subscription is canceled, for the amount of
$720.00 for Wur-Link (POTS Replacement). If SC Department of Employment &
Workforce makes changes to this subscription that affect these terms, this
agreement will remain in effect according to the updated terms.

In the event that an incorrect amount is debited from this account, I authorize
Wurtec, Inc. to credit this account in order to correct the situation. This
payment authorization is valid, in compliance with NACHA regulations, and will
remain in effect unless I, or another authorized user, notifies Wurtec, Inc. of
its cancellation by contacting Wurtec Subscription Services <setup@wurtec.com>
or 1-800-837-1066.

Signed,


* Authorizer First Name


* Authorizer Last Name


Merchant contact info:


1-800-837-1066


wurtecsales@wurtec.com


6200 Brent Drive, 43611 Toledo, US


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