Polk Technology Solutions, Inc. | A division of 1322 Consulting, Inc.

Payment


<html>
    <script src="https://nextyoupay.transactiongateway.com/token/Collect.js" data-tokenization-key="your-token-key-here" data-variant="inline"></script>
    <body>
        <h1>CollectJS Payment Form</h1>
        <form action="/your-page.php" method="post">
            <table>
                <tr>
                    <td>First Name</td>
                    <td><input size="30" type="text" name="fname" value="Test" /></td>
                </tr>
                <tr>
                    <td>Last Name</td>
                    <td><input size="30" type="text" name="lname" value="User" /></td>
                </tr>
                <tr>
                    <td>Address</td>
                    <td><input size="30" type="text" name="address" value="123 Main Street"></td>
                </tr>
                <tr>
                    <td>City</td>
                    <td><input size="30" type="text" name="city" value="Beverley Hills"></td>
                </tr>
                <tr>
                    <td>State</td>
                    <td><input size="30" type="text" name="state" value="CA"></td>
                </tr>
                <tr>
                    <td>Zip</td>
                    <td><input size="30" type="text" name="zip" value="90210"></td>
                </tr>
                <tr>
                    <td>Country</td>
                    <td><input size="30" type="text" name="country" value="US"></td>
                </tr>
                <tr>
                    <td>Phone</td>
                    <td><input size="30" type="text" name="phone" value="5555555555"></td>
                </tr>
                <tr>
                    <td colspan="2">
                        Credit Card Information
                    </td>
                </tr>
                <tr>
                    <td>CC Number</td>
                    <td id="ccnumber"></td>
                </tr>
                <tr>
                    <td>CC Exp</td>
                    <td id="ccexp"></td>
                </tr>
                <tr>
                    <td>CVV</td>
                    <td id="cvv"></td>
                </tr>
                <tr>
                    <td colspan="2">
                        Electronic Check Information
                    </td>
                </tr>
                <tr>
                    <td>Account Number</td>
                    <td id="checkaccount"></td>
                </tr>
                <tr>
                    <td>Routing Number</td>
                    <td id="checkaba"></td>
                </tr>
                <tr>
                    <td>Account Owner's Name</td>
                    <td id="checkname"></td>
                </tr>
            </table>
            <br>
            <button id="payButton" type="button">Submit Payment</button>
        </form>
    </body>
</html>