Romber

Example Payment Form

* Denotes required fields

* Account number:

* Document number:

* Card Type:

American Express
Diners Club
Mastercard
Visa

* Amount $:

* Card Number:

* Card Expiry:

* Name on Card:

Security code:

(Required for American Express)

See also the ROMBER_FORM.PHP documentation.

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Page modified on 28-Apr-2023