JSweb Technology
"Demonstration Order Form"
Secure Credit Card Order Form - Demonstration

Note: You may enter whatever fictious information you wish to fill out this form, except for your email address. You need to enter your correct email address, as you will receive an email giving you the user name and password to use for the second half of the demonstration.

Please provide the following contact
    First name
   Last name
Billing address
Address (cont.)
Zip/Postal code
E-mail (If you do not put your real email-address here, the rest of the demo will not work. The whole idea is for you to see what get's emailed to you, and what gets left securely on the server for you to retrieve.)
List Items Ordered
Total Cost


  Credit card

Cardholder name

  Card number
Expiration date


By pressing the Submit Order button below you authorize JSWeb Technology to bill your credit card as listed above.   You must be an authorized user of the credit card in order to place this order.

DEMO ONLY. No charges will be processed!

Thank You!