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
info: 








    First
name 





   Last name






Billing address






Address (cont.)






     
City





   
State/Province 





Zip/Postal code






Country






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





 

 
BILLING INFO







  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!