{"id":987495857,"date":"2022-10-06T14:10:40","date_gmt":"2022-10-06T18:10:40","guid":{"rendered":"https:\/\/www.barretteyecare.com\/?page_id=987495857"},"modified":"2023-03-03T16:34:11","modified_gmt":"2023-03-03T20:34:11","slug":"pay-your-bill","status":"publish","type":"page","link":"https:\/\/www.barretteyecare.com\/pay-your-bill\/","title":{"rendered":"Pay Your Bill"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; fullwidth=&#8221;on&#8221; admin_label=&#8221;Section&#8221; _builder_version=&#8221;4.18.0&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_fullwidth_post_title meta=&#8221;off&#8221; featured_image=&#8221;off&#8221; _builder_version=&#8221;4.18.0&#8243; _module_preset=&#8221;default&#8221; title_font=&#8221;|700||on|||||&#8221; title_text_align=&#8221;center&#8221; title_text_color=&#8221;#FFFFFF&#8221; title_font_size=&#8221;31px&#8221; background_color=&#8221;#07166B&#8221; min_height=&#8221;247px&#8221; custom_margin=&#8221;||0px||false|false&#8221; custom_padding=&#8221;150px||0px||false|false&#8221; animation_style=&#8221;bounce&#8221; animation_direction=&#8221;top&#8221; hover_enabled=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221; sticky_enabled=&#8221;0&#8243;][\/et_pb_fullwidth_post_title][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.18.0&#8243; _module_preset=&#8221;default&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;0px||||false|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.18.0&#8243; _module_preset=&#8221;default&#8221; hover_enabled=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221; width=&#8221;67%&#8221; module_alignment=&#8221;center&#8221; sticky_enabled=&#8221;0&#8243;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.18.0&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_code _builder_version=&#8221;4.18.0&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_4_container\" data-token=\"86ad6caf9793822643e98894a7759f76\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_paymybill\"  data-token=\"86ad6caf9793822643e98894a7759f76\">\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Pay My Bill<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"4\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_4\" id=\"frm_hide_fields_4\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"paymybill\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_4\" name=\"frm_submit_entry_4\" value=\"0b88ec4fa1\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/987495857\" \/><div id=\"frm_field_131_container\" class=\"frm_form_field form-field  frm_top_container frm6 frm_first\">\r\n    <label for=\"field_d7y13\" id=\"field_d7y13_label\" class=\"frm_primary_label\">Name:\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_d7y13\" name=\"item_meta[131]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_d7y13\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_d7y13\">First<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_132_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n    <label for=\"field_mr3k4\" id=\"field_mr3k4_label\" class=\"frm_primary_label\">Last\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_mr3k4\" name=\"item_meta[132]\" value=\"\"  data-reqmsg=\"Last cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_mr3k4\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_mr3k4\">Last<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_137_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_two_thirds frm_first\">\r\n    <label for=\"field_9vti6\" id=\"field_9vti6_label\" class=\"frm_primary_label\">Email:\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_9vti6\" name=\"item_meta[137]\" value=\"\"  data-reqmsg=\"Email: cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_138_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_third\">\r\n    <label for=\"field_x4nra\" id=\"field_x4nra_label\" class=\"frm_primary_label\">Phone Number:\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_x4nra\" name=\"item_meta[138]\" value=\"\"  placeholder=\"(___)_______\" data-reqmsg=\"Phone Number: cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_152_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <div  id=\"field_2n5sv_label\" class=\"frm_primary_label\">Billing Address\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <fieldset aria-labelledby=\"field_2n5sv_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tBilling Address<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_152-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_2n5sv_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\tBilling Address\t<\/label>\n\t\t<input type=\"text\" id=\"field_2n5sv_line1\" value=\"\" name=\"item_meta[152][line1]\"  data-reqmsg=\"Billing Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Billing Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_152-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_2n5sv_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\tBilling Address\t<\/label>\n\t\t<input type=\"text\" id=\"field_2n5sv_line2\" value=\"\" name=\"item_meta[152][line2]\"  data-reqmsg=\"Billing Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Billing Address is invalid\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_152-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_2n5sv_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_2n5sv_city\" value=\"\" name=\"item_meta[152][city]\"  data-reqmsg=\"Billing Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Billing Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_152-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_2n5sv_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\/Province\t<\/label>\n\t\t\t<select name=\"item_meta[152][state]\" id=\"field_2n5sv_state\"  data-reqmsg=\"Billing Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Billing Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level1\">\n\t\t\t<option value=\"\">\n\t\t\t\t \t\t\t<\/option>\n\t\t\t<option  value=\"Alabama\">Alabama<\/option><option  value=\"Alaska\">Alaska<\/option><option  value=\"Arkansas\">Arkansas<\/option><option  value=\"Arizona\">Arizona<\/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=\"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>\t\t<\/select>\n\t<div class=\"frm_description\">State\/Province<\/div><\/div>\n<div id=\"frm_field_152-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_2n5sv_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/Postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_2n5sv_zip\" value=\"\" name=\"item_meta[152][zip]\"  data-reqmsg=\"Billing Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Billing Address is invalid\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/Postal<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_143_container\" class=\"frm_form_field form-field  frm_top_container frm6 frm_first\">\r\n    <label for=\"field_t5p0\" id=\"field_t5p0_label\" class=\"frm_primary_label\">Account Number:\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_t5p0\" name=\"item_meta[143]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_144_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n    <label for=\"field_r6zua\" id=\"field_r6zua_label\" class=\"frm_primary_label\">Payment Amount\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_r6zua\" name=\"item_meta[144]\" value=\"\"  data-reqmsg=\"Payment Amount cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_150_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <div  id=\"field_5a60_label\" class=\"frm_primary_label\">Credit Card\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <fieldset aria-labelledby=\"field_5a60_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tCredit Card<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_150-cc_container\" class=\"frm_form_field form-field frm_full frm_cc_number\">\n\t<label for=\"field_5a60_cc\" class=\"frm_screen_reader frm_hidden\">\n\t\tCredit Card\t<\/label>\n\t\t<input type=\"tel\" id=\"field_5a60_cc\" value=\"\" name=\"item_meta[150][cc]\"  placeholder=\"Credit Card Information\"  data-invmsg=\"Credit Card is invalid\" aria-invalid=\"false\"   autocomplete=\"cc-number\" autocorrect=\"off\" spellcheck=\"off\" autocapitalize=\"off\" data-name=\"150-cc\" placeholder=\"Credit Card Information\" \/>\n\t<\/div>\n<div id=\"frm_field_150-month_container\" class=\"frm_form_field form-field frm_third frm_first frm_cc_exp_month\">\n\t<label for=\"field_5a60_month\" class=\"frm_screen_reader frm_hidden\">\n\t\tExp Month\t<\/label>\n\t\t\t<select name=\"item_meta[150][month]\" id=\"field_5a60_month\"  placeholder=\"Month\"  data-invmsg=\"Credit Card is invalid\" aria-invalid=\"false\"  >\n\t\t\t<option value=\"\">\n\t\t\t\tMonth\t\t\t<\/option>\n\t\t\t<option  value=\"1\">1<\/option><option  value=\"2\">2<\/option><option  value=\"3\">3<\/option><option  value=\"4\">4<\/option><option  value=\"5\">5<\/option><option  value=\"6\">6<\/option><option  value=\"7\">7<\/option><option  value=\"8\">8<\/option><option  value=\"9\">9<\/option><option  value=\"10\">10<\/option><option  value=\"11\">11<\/option><option  value=\"12\">12<\/option>\t\t<\/select>\n\t<div class=\"frm_description\">Exp Month<\/div><\/div>\n<div id=\"frm_field_150-year_container\" class=\"frm_form_field form-field frm_third frm_cc_exp_year\">\n\t<label for=\"field_5a60_year\" class=\"frm_screen_reader frm_hidden\">\n\t\tExp Year\t<\/label>\n\t\t\t<select name=\"item_meta[150][year]\" id=\"field_5a60_year\"  placeholder=\"Year\"  data-invmsg=\"Credit Card is invalid\" aria-invalid=\"false\"  >\n\t\t\t<option value=\"\">\n\t\t\t\tYear\t\t\t<\/option>\n\t\t\t<option  value=\"2024\">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>\t\t<\/select>\n\t<div class=\"frm_description\">Exp Year<\/div><\/div>\n<div id=\"frm_field_150-cvc_container\" class=\"frm_form_field form-field frm_third frm_cc_cvc\">\n\t<label for=\"field_5a60_cvc\" class=\"frm_screen_reader frm_hidden\">\n\t\tCVV Code\t<\/label>\n\t\t<input type=\"tel\" id=\"field_5a60_cvc\" value=\"\" name=\"item_meta[150][cvc]\"  placeholder=\"Security Code\"  data-invmsg=\"Credit Card is invalid\" aria-invalid=\"false\"   spellcheck=\"off\" autocapitalize=\"off\" maxlength=\"4\" autocorrect=\"off\" autocomplete=\"off\" data-name=\"150-cvc\" placeholder=\"Security Code\" \/>\n\t<div class=\"frm_description\">CVV Code<\/div><\/div>\n<\/div>\n<\/fieldset>\n<div class=\"frm-card-element\" id=\"field_5a60\"><\/div>\n<div class=\"frm-card-errors frm_error\" id=\"frm_error_field_5a60\" role=\"alert\"><\/div>\n\r\n    \r\n    \r\n<\/div>\n<input type=\"hidden\" name=\"item_meta[151]\" id=\"field_cztn2\" value=\"authnet_aim\"     \/>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t\t<div class=\"frm__65b172c8b5cbd\">\n\t\t\t\t<label for=\"frm_email_4\" >\n\t\t\t\t\tIf you are human, leave this field blank.\t\t\t\t<\/label>\n\t\t\t\t<input  id=\"frm_email_4\" type=\"text\" class=\"frm_verify\" name=\"frm__65b172c8b5cbd\" value=\"\" autocomplete=\"false\"  \/>\n\t\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"wHbt1w\/lMc0hvnXJuMiMXFdDEPbI9o+CzC1mkCPqr\/caaK1xjXl5NBj7ponQIpbh\" \/><div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"  >Submit Payment<\/button>\r\n\r\n<a href=\"#\" tabindex=\"0\" class=\"frm_start_over\" >Start Over<\/a>\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n<script type=\"text\/javascript\">var input = document.createElement('input');\n    input.setAttribute('type', 'hidden');\n    input.setAttribute('name', 'ct_checkjs_frm');\n    input.setAttribute('value', '140379241');\n    for (i = 0; i < document.forms.length; i++) {\n        if (typeof document.forms[i].id == 'string'){\n\t\t\tif(document.forms[i].id.search('form_paymybill') != -1) {\n            document.forms[i].appendChild(input);\n\t\t\t}\n        }\n    }<\/script>\n<\/form>\n<\/div>\n[\/et_pb_code][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_4_container\" data-token=\"86ad6caf9793822643e98894a7759f76\" data-token=\"86ad6caf9793822643e98894a7759f76\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_paymybill\"  data-token=\"86ad6caf9793822643e98894a7759f76\" data-token=\"86ad6caf9793822643e98894a7759f76\">\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Pay My Bill<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"4\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_4\" id=\"frm_hide_fields_4\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"paymybill\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_4\" name=\"frm_submit_entry_4\" value=\"0b88ec4fa1\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/987495857\" \/><div id=\"frm_field_131_container\" class=\"frm_form_field form-field  frm_top_container frm6 frm_first\">\r\n    <label for=\"field_d7y13\" id=\"field_d7y13_label\" class=\"frm_primary_label\">Name:\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_d7y13\" name=\"item_meta[131]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_d7y13\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_d7y13\">First<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_132_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n    <label for=\"field_mr3k4\" id=\"field_mr3k4_label\" class=\"frm_primary_label\">Last\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_mr3k4\" name=\"item_meta[132]\" value=\"\"  data-reqmsg=\"Last cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_mr3k4\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_mr3k4\">Last<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_137_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_two_thirds frm_first\">\r\n    <label for=\"field_9vti6\" id=\"field_9vti6_label\" class=\"frm_primary_label\">Email:\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_9vti6\" name=\"item_meta[137]\" value=\"\"  data-reqmsg=\"Email: cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_138_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_third\">\r\n    <label for=\"field_x4nra\" id=\"field_x4nra_label\" class=\"frm_primary_label\">Phone Number:\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_x4nra\" name=\"item_meta[138]\" value=\"\"  placeholder=\"(___)_______\" data-reqmsg=\"Phone Number: cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_152_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <div  id=\"field_2n5sv_label\" class=\"frm_primary_label\">Billing Address\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <fieldset aria-labelledby=\"field_2n5sv_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tBilling Address<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_152-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_2n5sv_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\tBilling Address\t<\/label>\n\t\t<input type=\"text\" id=\"field_2n5sv_line1\" value=\"\" name=\"item_meta[152][line1]\"  data-reqmsg=\"Billing Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Billing Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_152-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_2n5sv_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\tBilling Address\t<\/label>\n\t\t<input type=\"text\" id=\"field_2n5sv_line2\" value=\"\" name=\"item_meta[152][line2]\"  data-reqmsg=\"Billing Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Billing Address is invalid\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_152-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_2n5sv_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_2n5sv_city\" value=\"\" name=\"item_meta[152][city]\"  data-reqmsg=\"Billing Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Billing Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_152-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_2n5sv_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\/Province\t<\/label>\n\t\t\t<select name=\"item_meta[152][state]\" id=\"field_2n5sv_state\"  data-reqmsg=\"Billing Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Billing Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level1\">\n\t\t\t<option value=\"\">\n\t\t\t\t \t\t\t<\/option>\n\t\t\t<option  value=\"Alabama\">Alabama<\/option><option  value=\"Alaska\">Alaska<\/option><option  value=\"Arkansas\">Arkansas<\/option><option  value=\"Arizona\">Arizona<\/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=\"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>\t\t<\/select>\n\t<div class=\"frm_description\">State\/Province<\/div><\/div>\n<div id=\"frm_field_152-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_2n5sv_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/Postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_2n5sv_zip\" value=\"\" name=\"item_meta[152][zip]\"  data-reqmsg=\"Billing Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Billing Address is invalid\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/Postal<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_143_container\" class=\"frm_form_field form-field  frm_top_container frm6 frm_first\">\r\n    <label for=\"field_t5p0\" id=\"field_t5p0_label\" class=\"frm_primary_label\">Account Number:\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_t5p0\" name=\"item_meta[143]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_144_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n    <label for=\"field_r6zua\" id=\"field_r6zua_label\" class=\"frm_primary_label\">Payment Amount\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_r6zua\" name=\"item_meta[144]\" value=\"\"  data-reqmsg=\"Payment Amount cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_150_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <div  id=\"field_5a60_label\" class=\"frm_primary_label\">Credit Card\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <fieldset aria-labelledby=\"field_5a60_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tCredit Card<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_150-cc_container\" class=\"frm_form_field form-field frm_full frm_cc_number\">\n\t<label for=\"field_5a60_cc\" class=\"frm_screen_reader frm_hidden\">\n\t\tCredit Card\t<\/label>\n\t\t<input type=\"tel\" id=\"field_5a60_cc\" value=\"\" name=\"item_meta[150][cc]\"  placeholder=\"Credit Card Information\"  data-invmsg=\"Credit Card is invalid\" aria-invalid=\"false\"   autocomplete=\"cc-number\" autocorrect=\"off\" spellcheck=\"off\" autocapitalize=\"off\" data-name=\"150-cc\" placeholder=\"Credit Card Information\" \/>\n\t<\/div>\n<div id=\"frm_field_150-month_container\" class=\"frm_form_field form-field frm_third frm_first frm_cc_exp_month\">\n\t<label for=\"field_5a60_month\" class=\"frm_screen_reader frm_hidden\">\n\t\tExp Month\t<\/label>\n\t\t\t<select name=\"item_meta[150][month]\" id=\"field_5a60_month\"  placeholder=\"Month\"  data-invmsg=\"Credit Card is invalid\" aria-invalid=\"false\"  >\n\t\t\t<option value=\"\">\n\t\t\t\tMonth\t\t\t<\/option>\n\t\t\t<option  value=\"1\">1<\/option><option  value=\"2\">2<\/option><option  value=\"3\">3<\/option><option  value=\"4\">4<\/option><option  value=\"5\">5<\/option><option  value=\"6\">6<\/option><option  value=\"7\">7<\/option><option  value=\"8\">8<\/option><option  value=\"9\">9<\/option><option  value=\"10\">10<\/option><option  value=\"11\">11<\/option><option  value=\"12\">12<\/option>\t\t<\/select>\n\t<div class=\"frm_description\">Exp Month<\/div><\/div>\n<div id=\"frm_field_150-year_container\" class=\"frm_form_field form-field frm_third frm_cc_exp_year\">\n\t<label for=\"field_5a60_year\" class=\"frm_screen_reader frm_hidden\">\n\t\tExp Year\t<\/label>\n\t\t\t<select name=\"item_meta[150][year]\" id=\"field_5a60_year\"  placeholder=\"Year\"  data-invmsg=\"Credit Card is invalid\" aria-invalid=\"false\"  >\n\t\t\t<option value=\"\">\n\t\t\t\tYear\t\t\t<\/option>\n\t\t\t<option  value=\"2024\">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>\t\t<\/select>\n\t<div class=\"frm_description\">Exp Year<\/div><\/div>\n<div id=\"frm_field_150-cvc_container\" class=\"frm_form_field form-field frm_third frm_cc_cvc\">\n\t<label for=\"field_5a60_cvc\" class=\"frm_screen_reader frm_hidden\">\n\t\tCVV Code\t<\/label>\n\t\t<input type=\"tel\" id=\"field_5a60_cvc\" value=\"\" name=\"item_meta[150][cvc]\"  placeholder=\"Security Code\"  data-invmsg=\"Credit Card is invalid\" aria-invalid=\"false\"   spellcheck=\"off\" autocapitalize=\"off\" maxlength=\"4\" autocorrect=\"off\" autocomplete=\"off\" data-name=\"150-cvc\" placeholder=\"Security Code\" \/>\n\t<div class=\"frm_description\">CVV Code<\/div><\/div>\n<\/div>\n<\/fieldset>\n<div class=\"frm-card-element\" id=\"field_5a60\"><\/div>\n<div class=\"frm-card-errors frm_error\" id=\"frm_error_field_5a60\" role=\"alert\"><\/div>\n\r\n    \r\n    \r\n<\/div>\n<input type=\"hidden\" name=\"item_meta[151]\" id=\"field_cztn2\" value=\"authnet_aim\"     \/>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t\t<div class=\"frm__65b172c8b5cbd\">\n\t\t\t\t<label for=\"frm_email_4\" >\n\t\t\t\t\tIf you are human, leave this field blank.\t\t\t\t<\/label>\n\t\t\t\t<input  id=\"frm_email_4\" type=\"text\" class=\"frm_verify\" name=\"frm__65b172c8b5cbd\" value=\"\" autocomplete=\"false\"  \/>\n\t\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"wHbt1w\/lMc0hvnXJuMiMXFdDEPbI9o+CzC1mkCPqr\/caaK1xjXl5NBj7ponQIpbh\" \/><div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"  >Submit Payment<\/button>\r\n\r\n<a href=\"#\" tabindex=\"0\" class=\"frm_start_over\" >Start Over<\/a>\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n<script type=\"text\/javascript\">var input = document.createElement('input');\n    input.setAttribute('type', 'hidden');\n    input.setAttribute('name', 'ct_checkjs_frm');\n    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