<?
if (!$_SERVER['HTTPS']) { 
    header ('HTTP/1.1 301 Moved Permanently'); 
    header ("location:https://www.charge.com/fdapp.html"); 
}
include_once ('/home/chargec/includes/lib.php');

$ipLog = "/home/{$GLOBALS['account']}/logs/signup.log";
$blockerror = "Charge.com is unable to process your request at this time.  Please try again later.";
if (ipBlocker($_SERVER['REMOTE_ADDR'], 15, 3600, $ipLog) && $_SERVER['REMOTE_ADDR'] != '') {
    echo $blockerror;
    exit();
}

// block this ip for malicious actions
if($_SERVER['REMOTE_ADDR'] == '62.210.141.31'){
    exit;
}

function validate_post(){
    // trim and map to new array
    $trimmed_post = array_map('trim', $_POST);
    
    $field_list = array('Legal_business_name','DBA','Email_address','Business_phone_number','Business_fax_number',
                        'Business_street_address','Business_city','Business_state','Business_zip','Website_address',
                        'Number_of_employees','Business_location','First_name','Last_name','Title','Ownership_%','DOB_Month',
                        'DOB_Day','DOB_Year','Social_Security_Number','Drivers_license_number','State_issued','DL_Month','DL_Day',
                        'DL_Year','Home_phone','Home_address','Home_city','Home_state','Home_zip','Describe_products_and_services_sold_in_detail',
                        'Estimated_monthly_credit_card_sales_volume','Estimated_average_individual_credit_card_transaction_size',
                        'Estimated_highest_credit_card_sale_amount','Refund_Policy','Business_Structure','Month_formed','Year_formed',
                        'Name_of_processor','Terminal','Imprint','Mail-phone-fax_order','Internet','0-7_days','8-14_days',
                        '15-30_days','Over_30_days','Federal_Tax_ID_Number','Bank_Name','Bank_Account_Number','Bank_Routing_Number');
    
    $result = array('fatal_error' => FALSE, 'errors' => array());
    
    // first check to see if all fields are present
    foreach($field_list as $field){
        if(!isset($trimmed_post[$field])){
            $result['fatal_error'] = TRUE;
            $result['errors'][] = "Missing form field: {$field}";
        }
    }
    if($result['fatal_error'] === TRUE){ // fatal, get out now!
        return $result;
    }
    
    $non_required_fields = array('DBA', 'Business_fax_number', 'Website_address', 
                                 'Name_of_processor', 'Terminal', 'Imprint', 
                                 'Mail-phone-fax_order', 'Internet', '0-7_days', 
                                 '8-14_days', '15-30_days', 'Over_30_days');
    
    // validate email
    if(!filter_var($trimmed_post['Email_address'], FILTER_VALIDATE_EMAIL)) {
        $result['errors'][] = 'Email_address';
    }
    
    $num_fields = array('Estimated_average_individual_credit_card_transaction_size','Estimated_highest_credit_card_sale_amount',
                    'Terminal','Imprint','Mail-phone-fax_order','Internet','0-7_days','8-14_days','15-30_days','Over_30_days',
                    'Number_of_employees','Ownership_%','DOB_Month','DOB_Day','DOB_Year','DL_Month','DL_Day','DL_Year',
                    'Estimated_monthly_credit_card_sales_volume','Month_formed','Year_formed','Estimated_monthly_credit_card_sales_volume');
    foreach($num_fields as $field){
        if(strlen($trimmed_post[$field]) > 0 && filter_var($trimmed_post[$field], FILTER_VALIDATE_FLOAT) === FALSE) {
            $result['errors'][] = $field;
        }
    }
    
    $phone_fields = array('Business_phone_number','Business_fax_number','Home_phone');
    foreach($phone_fields as $field){
        if(!in_array($field, $non_required_fields) || strlen($trimmed_post[$field]) > 0){
            $stripped_phone = preg_replace("/[^0-9]/", '', $trimmed_post[$field]);
            if($stripped_phone[0] == '1'){
                // remove leading 1
                $stripped_phone = substr($stripped_phone, 1);
            }
            if(strlen($stripped_phone) != 10){
                $result['errors'][] = $field;
            }
        }
    }
    
    $nine_digit_fields = array('Bank_Routing_Number','Federal_Tax_ID_Number', 'Social_Security_Number');
    foreach($nine_digit_fields as $field){
        if(!in_array($field, $non_required_fields) || strlen($trimmed_post[$field]) > 0){
            $stripped_field = preg_replace("/[^0-9]/", '', $trimmed_post[$field]);
            if(strlen($stripped_field) != 9){
                $result['errors'][] = $field;
            }
        }
    }
    
    $zip_fields = array('Business_zip','Home_zip');
    foreach($zip_fields as $field){
        if(!preg_match('/(^\d{5}$)|(^\d{5}-\d{4}$)/', $trimmed_post[$field])){
            $result['errors'][] = $field;
        }
    }
    
    $required_text_fields = array('Legal_business_name','Business_street_address','Business_city','Business_state',
                                  'Business_location','First_name','Last_name','Title','State_issued','Home_address',
                                  'Home_city','Home_state','Describe_products_and_services_sold_in_detail',
                                  'Refund_Policy','Business_Structure','Bank_Name','Bank_Account_Number');
    foreach($required_text_fields as $field){
        if(strlen($trimmed_post[$field]) < 1){
            $result['errors'][] = $field;
        }
    }
    
    return $result;
}

$stArr = array (''=>'&mdash;Select&mdash;',
                'AL'=>'Alabama','AK'=>'Alaska',
                'AZ'=>'Arizona','AR'=>'Arkansas',
                'CA'=>'California','CO'=>'Colorado',
                'CT'=>'Connecticut','DE'=>'Delaware',
                'DC'=>'District of Columbia','FL'=>'Florida',
                'GA'=>'Georgia','HI'=>'Hawaii','ID'=>'Idaho',
                'IL'=>'Illinois','IN'=>'Indiana','IA'=>'Iowa',
                'KS'=>'Kansas','KY'=>'Kentucky','LA'=>'Louisiana',
                'ME'=>'Maine','MD'=>'Maryland','MA'=>'Massachusetts',
                'MI'=>'Michigan','MN'=>'Minnesota','MS'=>'Mississippi',
                'MO'=>'Missouri','MT'=>'Montana','NE'=>'Nebraska',
                'NV'=>'Nevada','NH'=>'New Hampshire','NJ'=>'New Jersey',
                'NM'=>'New Mexico','NY'=>'New York','NC'=>'North Carolina',
                'ND'=>'North Dakota','OH'=>'Ohio','OK'=>'Oklahoma',
                'OR'=>'Oregon','PA'=>'Pennsylvania','RI'=>'Rhode Island',
                'SC'=>'South Carolina','SD'=>'South Dakota','TN'=>'Tennessee',
                'TX'=>'Texas','UT'=>'Utah','VT'=>'Vermont','VA'=>'Virginia',
                'WA'=>'Washington','WV'=>'West Virginia','WI'=>'Wisconsin','WY'=>'Wyoming');
if ($_POST) {
    array_pop ($_POST);
    $validation_result = validate_post();
    if($validation_result['fatal_error'] === TRUE){
        say("Fatal error: ".print_r($validation_result['errors'], TRUE));
        exit;
    }
    if(empty($validation_result['errors'])){
        $_POST['Submitted_from'] = $_SERVER['REMOTE_ADDR'];
        foreach ($_POST as $k => $v) {
            $sanatized_key = filter_var($k, FILTER_SANITIZE_STRING, FILTER_FLAG_NO_ENCODE_QUOTES);
            $sanatized_value = filter_var($v, FILTER_SANITIZE_STRING, FILTER_FLAG_NO_ENCODE_QUOTES);
            $bg = ($i%2)?'#ccc':'#fff';
            $body[] = "<tr style=\"background:$bg\"><td>".str_replace ("_", " ", $sanatized_key).": </td><td>{$sanatized_value}</td></tr>";
            $i++;
        }
        $html = "<html><body><table>\n".implode ("\n", $body)."</table></body></html>\n";
        require_once ('/home/chargec/includes/Emailing/EmailService.php');
        $mail = new EmailService();
        try {
            $mail->AddReplyTo($_POST['Email_address'], 'CSI Application');
            $mail->SetFrom($_POST['Email_address'], 'CSI Application');
            $mail->AddAddress('webdr@charge.com', 'Web Dr');
            $mail->AddAddress('gdanzig@charge.com', 'Greg Danzig');
            $mail->Subject = 'CSI Application';
            $mail->MsgHTML($html);
            $mail->Send();
            $success = true;
        }
        catch (phpmailerException $e) {
            say($e->errorMessage()); //Pretty error messages from PHPMailer
        }
        catch (Exception $e) {
            say($e->getMessage()); //Boring error messages from anything else!
        }
     }else{ // failed server side validation
         say("Server side validation errors: ".print_r($validation_result['errors'], TRUE));
         
         $validation_result_js = "<script> ";
         foreach($validation_result['errors'] as $field){
            $validation_result_js .= "if(document.getElementById('{$field}') !== null){ ";
            $validation_result_js .= "document.getElementById('{$field}').style.backgroundColor = '#ff9'; ";
            $validation_result_js .= "} ";
         }
         foreach($_POST as $key => $value){
             $validation_result_js .= "if(document.getElementById('{$key}') !== null){ ";
             $validation_result_js .= "document.getElementById('{$key}').value = '{$value}'; ";
             $validation_result_js .= "} ";
         }
         $validation_result_js .= "scroll(0, 70); ";
         $validation_result_js .= "document.getElementById('errDiv').style.display = 'block'; ";
         $validation_result_js .= "document.getElementById('welcome').style.display = 'none'; ";
         $validation_result_js .= "percentSum(document.getElementById('Terminal')); ";
         $validation_result_js .= "percentSum(document.getElementById('0-7_days')); ";
         $validation_result_js .= '</script>';
         
        $mail = new EmailService();
        try {
            $mail->AddReplyTo('webdr@charge.com', 'Web Dr');
            $mail->SetFrom('webdr@charge.com', 'Web Dr');
            $mail->AddAddress('webdr@charge.com', 'Web Dr');
            $mail->Subject = 'CSI Application - Failed Server Side Validation';
            $mail->Body = "Server side valication failed\r\n\r\n".print_r($validation_result['errors'], TRUE);
            $mail->Send();
        }
        catch (phpmailerException $e) {
            say($e->errorMessage()); //Pretty error messages from PHPMailer
        }
        catch (Exception $e) {
            say($e->getMessage()); //Boring error messages from anything else!
        }
     }
 }
 
$first_name = '';
$last_name = ''; 
$phone_business = '';
$company = '';
$email = '';
if ($_SERVER['QUERY_STRING']) {
    $hash = filter_var($_SERVER['QUERY_STRING'], FILTER_SANITIZE_STRING);
    $sql = '';
    $escaped_hash = mysqli_real_escape_string ($GLOBALS['mysqli_link'],$hash);
    if(strlen($hash) === 20){
        $sql = "SELECT * FROM `apps` WHERE `hash` = '{$escaped_hash}' LIMIT 1";
    }else if(strlen($hash) >= 20) {
        $sql = "SELECT * FROM `apps` WHERE `csi_mid` = '{$escaped_hash}' LIMIT 1";
    }
    if($sql !== '') {    
        $row = mysqli_wrap ($sql);   
        $id = $row[0];
        if (!empty ($id)) {
            $first_name = $row['first_name'];
            $last_name = $row['last_name']; 
            $phone_business = $row['phone_business'];
            $company = $row['company'];
            $email = $row['email'];
        }
    }
}
if(!empty($hash)) {
    $post_url = "fdapp.html?{$hash}";
} else {
    $post_url = "fdapp.html";
}
?>
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN"	"http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml" xml:lang="en" lang="en">
<head>
 <title>Free Charge.com Signup</title>
 <meta name="description" content="Provides online home based and small business owners with a merchant account to accept credit cards.  Free ecommerce shopping cart." />
 <meta name="keywords" content="merchant accounts" />
 <meta http-equiv="Content-Type" content="text/html;charset=utf-8" />
 <link rel="stylesheet" href="https://www.charge.com/cc.css" />
 <link rel="stylesheet" href="https://www.charge.com/signupfree2.css" />
 <style type="text/css">
  td{margin:3px;}
  input[type='text'],select{width:150px;}
  select{width:155px;}
  span{color:#c00;padding:0 3px;}
  table{margin:auto;}
  body{margin-bottom:0;}
 </style>
<script type="text/javascript" src="https://www.charge.com/CSI.form.js"></script>
</head>
<body>
<div style="text-align: center; background-color: #1b134f; width: 100%;height:75px;">
 <div style="width:800px;margin-left:auto;margin-right:auto;padding-top:15px;">
  <img src="https://www.charge.com/images/chargelogo.longform.gif" width="200" height="56" alt="Charge.com" id="img1" />
  <img src="https://www.charge.com/images/cards.longform.gif" width="271" height="39" alt="Accept Credit Cards" id="img2" />
 </div>
</div>
<?if ($success){?>
<br />
<div id="welcome" style="width:750px;margin:auto;">
 <p>Dear <?=$_POST['First_name']?> <?=$_POST['Last_name']?>,</p>
 <p>Thank you for choosing Charge.com for your credit card processing needs.  We will contact you shortly regarding the status of your account.</p>
 <p>We look forward to serving you and your business.</p>
 <p>Warm regards,</p>
 <div>The Charge.com Support Team</div>
</div>
<span id="lblFoot">
 <div style="text-align:center;background-color:#fff;">
  <div style="width:700px;padding:50px 0 50px 0;margin: 0 auto;" class="ss10pxgrey">
   <div style="padding-bottom:12px;">&copy;Charge.com Payment Solutions, Inc., 2009.</div>
   <div>Charge.com Payment Solutions Inc., is a registered ISO/MSP.</div>
   <div>American Express requires separate approval.</div>
   <div><a style="font-size:10px;color:#999;" href="https://www.charge.com/privacy_policy.aspx">Privacy Policy</a></div>
  </div>
 </div>
</span>
</html>
</body>
<?exit;?>
<?}?>
<div style="line-height: 1px; background-color: #f6dc2d; width: 100%; margin: 0; font-size: 1px;">&nbsp;</div>
<div>
 <div id="welcome" style="width:750px;margin:auto;">
  <h1 style="text-align:center;margin-top:1em;color:#000;">New Account Activation</h1>
  <p>Congratulations! You are on your way to increasing your sales and profits by accepting credit cards for your business.</p>
  <p>For your privacy and security, your account information is kept safe with the highest grade of commercially available encryption. Your information will be kept completely confidential and will not be shared with anyone.</p>
  <p>In order to complete the setup and activation process and start accepting credit cards from your customers, please provide us with the information requested below.</p>
  <p>Required items are marked with (<span style="color:#c00;">*</span>)</p>
 </div>
 <div id="errDiv" style="display:none;width:750px;;margin:auto;color:#c00;font-weight:bold;font-size:1.2em;padding-top:1em;">
  Please complete all required fields and correct any invalid entries.
 </div>
<form method="post" action="<?=htmlentities($post_url)?>" id="form" name="form" onsubmit="return validate(this);">
<table align="center">
<tr><td colspan="2"><img src="https://www.charge.com/images/longform.merchant-information.gif" width="183" height="15" alt="Merchant Information" style="border:0;margin:15px 4px 5px 0;" /></td></tr>
<tr><td><span>*</span>Legal Business Name</td><td><input type="text" id="Legal_business_name" name="Legal_business_name" value="<?=$company?>" /></td></tr>
<tr><td><span style="color:#fff;">*</span>Doing Business As (DBA) (if applicable)</td><td><input type="text" id="DBA" name="DBA" value="" /></td></tr>
<tr><td><span>*</span>Email Address</td><td><input type="text" id="Email_address" name="Email_address" value="<?=$email?>" /></td></tr>
<tr><td><span>*</span>Business Phone Number</td><td><input type="text" id="Business_phone_number" name="Business_phone_number" value="<?=$phone_business?>" /></td></tr>
<tr><td><span style="color:#fff;">*</span>Business Fax Number (optional)</td><td><input type="text" id="Business_fax_number" name="Business_fax_number" value="" /></td></tr>
<tr><td><span>*</span>Business Street Address (No PO Boxes)</td><td><input type="text" id="Business_street_address" name="Business_street_address" value="" /></td></tr>
<tr><td><span>*</span>Business City</td><td><input type="text" id="Business_city" name="Business_city" value="" /></td></tr>
<tr><td><span>*</span>Business State</td><td><select id="Business_state" name="Business_state"><?foreach($stArr as $k=>$v){?><option value="<?=$k?>"<?=($k==$appArr['state'])?' selected="selected"':''?>><?=$v?></option><?}?></select></td></tr>
<tr><td><span>*</span>Business Zip</td><td><input type="text" id="Business_zip" name="Business_zip" value="" /></td></tr>
<tr><td><span style="color:#fff;">*</span>Website Address (if applicable)</td><td><input type="text" id="Website_address" name="Website_address" value="" /></td></tr>
<tr><td><span>*</span>Number of Employees</td><td><input type="text" id="Number_of_employees" name="Number_of_employees" value="" /></td></tr>
<tr><td><span>*</span>Business Location</td><td><select id="Business_location" name="Business_location">
<option value="">&mdash;Select&mdash;</option>
<option value="Mall">Mall</option>
<option value="Office">Office</option>
<option value="Home">Home</option>
<option value="Shopping Area">Shopping Area</option>
<option value="Mixed">Mixed</option>
<option value="Apartment">Apartment</option>
<option value="Isolated">Isolated</option></select>
</td></tr>
<tr><td colspan="2"><img src="https://www.charge.com/images/longform.owner-information.gif" width="159" height="15" alt="Owner Information" style="border:0;margin:15px 4px 5px 0;" /></td></tr>
<tr><td><span>*</span>First Name</td><td><input type="text" id="First_name" name="First_name" value="<?=$first_name?>" /></td></tr>
<tr><td><span>*</span>Last Name</td><td><input type="text" id="Last_name" name="Last_name" value="<?=$last_name?>" /></td></tr>
<tr><td><span>*</span>Title</td><td><input type="text" id="Title" name="Title" value="" /></td></tr>
<tr><td><span>*</span>Ownership Percentage</td><td><input type="text" id="Ownership_%" name="Ownership_%" value="" /> %</td></tr>
<tr><td><span>*</span>Date of Birth</td><td>
 <select id="DOB_Month" name="DOB_Month" style="width:47px;"><option value="">mm</option><?for($i=1; $i<13; $i++){?><option value="<?=$i?>"><?=$i?></option><?}?></select>/
 <select id="DOB_Day" name="DOB_Day" style="width:40px;"><option value="">dd</option><?for($i=1; $i<32; $i++){?><option value="<?=$i?>"><?=$i?></option><?}?></select>/
 <select id="DOB_Year" name="DOB_Year" style="width:53px;"><option value="">yyyy</option><?for($i=1900; $i<(date('Y')+1); $i++){?><option value="<?=$i?>"><?=$i?></option><?}?></select></td></tr>
<tr><td><span>*</span>Social Security Number</td><td><input type="text" id="Social_Security_Number" name="Social_Security_Number" value="" /></td></tr>
<tr><td><span>*</span>Drivers License Number</td><td><input type="text" id="Drivers_license_number" name="Drivers_license_number" value="" /></td></tr>
<tr><td><span>*</span>State Issued</td><td><select id="State_issued" name="State_issued"><?foreach($stArr as $k=>$v){?><option value="<?=$k?>"<?=($k==$appArr['state'])?' selected="selected"':''?>><?=$v?></option><?}?></select></td></tr>
<tr><td><span>*</span>Expiration Date</td><td><select id="DL_Month" name="DL_Month" style="width:47px;"><option value="">mm</option><?for($i=1; $i<13; $i++){?><option value="<?=$i?>"><?=$i?></option><?}?></select>/
 <select id="DL_Day" name="DL_Day" style="width:40px;"><option value="">dd</option><?for($i=1; $i<32; $i++){?><option value="<?=$i?>"><?=$i?></option><?}?></select>/
 <select id="DL_Year" name="DL_Year" style="width:53px;"><option value="">yyyy</option><?for($i=date('Y'); $i<(date('Y')+8); $i++){?><option value="<?=$i?>"><?=$i?></option><?}?></select></td></tr>
<tr><td><span>*</span>Home Phone</td><td><input type="text" id="Home_phone" name="Home_phone" value="" /></td></tr>
<tr><td><span>*</span>Home Address</td><td><input type="text" id="Home_address" name="Home_address" value="" /></td></tr>
<tr><td><span>*</span>Home City</td><td><input type="text" id="Home_city" name="Home_city" value="" /></td></tr>
<tr><td><span>*</span>Home State</td><td><select id="Home_state" name="Home_state"><?foreach($stArr as $k=>$v){?><option value="<?=$k?>"<?=($k==$appArr['state'])?' selected="selected"':''?>><?=$v?></option><?}?></select></td></tr>
<tr><td><span>*</span>Home Zip</td><td><input type="text" id="Home_zip" name="Home_zip" value="" /></td></tr>
<tr><td colspan="2"><img src="https://www.charge.com/images/longform.business-information.gif" width="174" height="15" alt="Business Information" style="border:0;margin:10px 4px 5px 0;" /></td></tr>
<tr><td><span>*</span>Describe Products and Services Sold in Detail</td><td><input type="text" id="Describe_products_and_services_sold_in_detail" name="Describe_products_and_services_sold_in_detail" value="" /></td></tr>
<tr><td><span>*</span><div style="float:right;">&nbsp;$</div>Total Monthly Credit Card Sales (estimated)</td><td><input type="text" id="Estimated_monthly_credit_card_sales_volume" name="Estimated_monthly_credit_card_sales_volume" value="" /></td></tr>
<tr><td><span>*</span><div style="float:right;">&nbsp;$</div>Average Individual Credit Card Sale Amount (estimated)</td><td><input type="text" id="Estimated_average_individual_credit_card_transaction_size" name="Estimated_average_individual_credit_card_transaction_size" value="" /></td></tr>
<tr><td><span>*</span><div style="float:right;">&nbsp;$</div>Highest Individual Credit Card Sale Amount (estimated)</td><td><input type="text" id="Estimated_highest_credit_card_sale_amount" name="Estimated_highest_credit_card_sale_amount" value="" /></td></tr>
<tr><td><span>*</span>What Is Your Refund Policy?</td><td><select id="Refund_Policy" name="Refund_Policy"><option value="">&ndash;Select&ndash;</option><option value="full refund">full refund</option><option value="exchange only">exchange only</option><option value="no refunds">no refunds</option></select></td></tr>
<tr><td><span>*</span>Business Structure:</td><td><select id="Business_Structure" name="Business_Structure"><option value="">&ndash;Select&ndash;</option><option value="Sole proprietorship">Sole proprietorship</option><option value="Corporation">Corporation</option><option value="LLC">LLC</option><option value="Partnership">Partnership</option><option value="Non-profit">Non-profit</option></select></td></tr>
<tr><td><span>*</span>Month and Year Business Formed</td><td><select id="Month_formed" name="Month_formed" style="width:75px;"><option value="">&ndash;Month&ndash;</option><?for ($i=1; $i<13; $i++){?><option value="<?=$i?>"><?=$i?></option><?}?></select> / <select id="Year_formed" name="Year_formed" style="width:68px;"><option value="">&ndash;Year&ndash;</option><?for ($i=date('Y'); $i>1899; $i--){?><option value="<?=$i?>"><?=$i?></option><?}?></select></td></tr>
<tr><td><span>*</span>Are you now processing or have you ever&nbsp;<br /><span style="color:#fff;">*</span>processed credit cards for this business?</td><td id="Currently_Accept_Cards_td"><input id="Currently_Accept_Cards_Yes" type="radio" name="Currently_Accept_Cards" value="Yes" onclick="document.getElementById('NoP').style.display=tbDisp;" />Yes <input id="Currently_Accept_Cards_No" type="radio" name="Currently_Accept_Cards" value="No" onclick="document.getElementById('NoP').style.display='none';" />No</td></tr>
<tr id="NoP" style="display:none;"><td><span>*</span>Name of processor</td><td><input type="text" name="Name_of_processor" value="" /></td></tr>
<tr><td><span>*</span>Do you wish to accept American Express?</td><td id="American_Express_td"><input id="American_Express_yes" type="radio" name="American_Express" value="Yes" />Yes <input id="American_Express_no" type="radio" name="American Express" value="No" />No</td></tr>
<tr><td colspan="2"><span style="color:#fff;">*</span>Please provide expected percentages for each method of accepting credit cards.<br /><span style="color:#fff;">*</span>The percentages you enter must total 100%</td></tr>
<tr><td><span>*</span>Card swipe through a terminal</td><td><input type="text" id="Terminal" name="Terminal" value="" size="3" style="width:28px;" onchange="return percentSum(this);" /> %</td></tr>
<tr><td><span>*</span>Imprint of card with signature without swipe</td><td><input type="text" id="Imprint" name="Imprint" value="" size="3" style="width:28px;" onchange="return percentSum(this);" /> %</td></tr>
<tr><td><span>*</span>Mail/phone/fax order</td><td><input type="text" id="Mail-phone-fax_order" name="Mail-phone-fax_order" value="" size="3" style="width:28px;" onchange="return percentSum(this);" /> %</td></tr>
<tr><td><span>*</span>Internet</td><td><input type="text" id="Internet" name="Internet" value="" size="3" style="width:28px;" onchange="return percentSum(this);" /> %</td></tr>
<tr><td><span>*</span>Total:</td><td><input disabled="disabled" name="pctTotal" id="pctTotal" style="background:#fafafa;width:30px;" size="3" value="" /> %</td></tr>
<tr><td colspan="2"><span style="color:#fff;">*</span>What is the timeframe from the credit card transaction to delivery of the product/service?<br /><span style="color:#fff;">*</span>The percentages you enter must total 100</td></tr>
<tr><td><span>*</span>0-7 days</td><td><input type="text" id="0-7_days" name="0-7_days" value="" size="3" style="width:28px;" onchange="return percentSum(this);" /> %</td></tr>
<tr><td><span>*</span>8-14 days</td><td><input type="text" id="8-14_days" name="8-14_days" value="" size="3" style="width:28px;" onchange="return percentSum(this);" /> %</td></tr>
<tr><td><span>*</span>15-30 days</td><td><input type="text" id="15-30_days" name="15-30_days" value="" size="3" style="width:28px;" onchange="return percentSum(this);" /> %</td></tr>
<tr><td><span>*</span>Over 30 days</td><td><input type="text" id="Over_30_days" name="Over_30_days" value="" size="3" style="width:28px;" onchange="return percentSum(this);" /> %</td></tr>
 <tr><td><span>*</span>Total:</td><td><input disabled="disabled" name="transTotal" id="transTotal" style="background:#fafafa;width:30px;" size="3" value="" /> %</td></tr>
<tr><td><span>*</span>Federal Tax ID Number</td><td><input type="text" id="Federal_Tax_ID_Number" name="Federal_Tax_ID_Number" value="" /></td></tr>
<tr><td colspan="2"><span style="color:#fff;">*</span><img src="https://www.charge.com/images/check-sample.png" alt="Sample check" width="359" height="240" style="margin:2em 0;border:0" /></td></tr>
<tr><td><span>*</span>Bank Name</td><td><input type="text" id="Bank_Name" name="Bank_Name" value="" /></td></tr>
<tr><td><span>*</span>Bank Account Number</td><td><input type="text" id="Bank_Account_Number" name="Bank_Account_Number" value="" /></td></tr>
<tr><td><span>*</span>Bank Routing Number</td><td><input type="text" id="Bank_Routing_Number" name="Bank_Routing_Number" value="" /></td></tr>
<tr><td>&nbsp;</td><td><input type="submit" name="submit" value="Submit" style="margin:1em 0;" /></td></tr>
</table>
</form>
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