{"id":259592,"date":"2025-08-25T16:36:30","date_gmt":"2025-08-25T21:36:30","guid":{"rendered":"https:\/\/mfe-is.com\/?post_type=wp-landing-page&#038;p=259592"},"modified":"2025-08-29T15:34:59","modified_gmt":"2025-08-29T20:34:59","slug":"credit-card-authorization-form","status":"publish","type":"page","link":"https:\/\/mfe-is.com\/fr\/credit-card-authorization-form\/","title":{"rendered":"MFE Credit Card Authorization Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"259592\" class=\"elementor elementor-259592\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-5800568 e-flex e-con-boxed e-con e-parent\" data-id=\"5800568\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-1910201 elementor-widget__width-initial elementor-widget elementor-widget-heading\" data-id=\"1910201\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">MFE Credit Card Authorization Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-45b1ee2b e-flex e-con-boxed e-con e-parent\" data-id=\"45b1ee2b\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-6acd96e9 e-flex e-con-boxed e-con e-child\" data-id=\"6acd96e9\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-7f3ab59b elementor-widget elementor-widget-html\" data-id=\"7f3ab59b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_62' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Credit Card Authorization Form<\/h2>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>\u00ab\u00a0<span class=\"gfield_required gfield_required_asterisk\">*<\/span>\u00a0\u00bb indique les champs n\u00e9cessaires<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_62'  action='\/fr\/wp-json\/wp\/v2\/pages\/259592' data-formid='62' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_62' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_62_32\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_62_32'>Name<\/label><div class='gfield_description' id='gfield_description_62_32'>Ce champ n\u2019est utilis\u00e9 qu\u2019\u00e0 des fins de validation et devrait rester inchang\u00e9.<\/div><div class='ginput_container'><input name='input_32' id='input_62_32' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_62_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_62_6'>Invoice or Contract #<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_62_6' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_62_7\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_62_7'>MFE Contact&#039;s Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_62_7' type='email' value='' class='large'   placeholder='example@mfe-is.com' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_62_5\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Customer&#039;s Information<\/h3><\/div><fieldset id=\"field_62_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Customer&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_62_1'>\n                            \n                            <span id='input_62_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_62_1_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                    <input type='text' name='input_1.3' id='input_62_1_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            \n                            <span id='input_62_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_62_1_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                            <input type='text' name='input_1.6' id='input_62_1_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_62_2\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Customer&#039;s Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_62_2_container'>\n                                <span id='input_62_2_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_62_2' class='gform-field-label gform-field-label--type-sub '>Saisissez une adresse courriel<\/label>\n                                    <input class='' type='email' name='input_2' id='input_62_2' value=''   placeholder='example@company.com' aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <span id='input_62_2_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_62_2_2' class='gform-field-label gform-field-label--type-sub '>Confirmez l\u2019adresse courriel<\/label>\n                                    <input class='' type='email' name='input_2_2' id='input_62_2_2' value=''   placeholder='example@company.com' aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_62_8\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_62_8'>Customer&#039;s Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_62_8' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_62_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_62_9'>Your Company&#039;s Legal Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_62_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_62_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_62_10'>Your Company&#039;s DBA Name (if applicable)<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_62_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_62_11\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Customer&#039;s Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_62_11' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_62_11_1_container' >\n                                        <label for='input_62_11_1' id='input_62_11_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                        <input type='text' name='input_11.1' id='input_62_11_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_62_11_2_container' >\n                                        <label for='input_62_11_2' id='input_62_11_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                        <input type='text' name='input_11.2' id='input_62_11_2' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_62_11_3_container' >\n                                    <label for='input_62_11_3' id='input_62_11_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                    <input type='text' name='input_11.3' id='input_62_11_3' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_62_11_4_container' >\n                                        <label for='input_62_11_4' id='input_62_11_4_label' class='gform-field-label gform-field-label--type-sub '>\u00c9tat \/ Province \/ R\u00e9gion<\/label>\n                                        <input type='text' name='input_11.4' id='input_62_11_4' value=''      aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_62_11_5_container' >\n                                    <label for='input_62_11_5' id='input_62_11_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Code postal<\/label>\n                                    <input type='text' name='input_11.5' id='input_62_11_5' value=''    aria-required='true'    \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_62_11_6_container' >\n                                        <label for='input_62_11_6' id='input_62_11_6_label' class='gform-field-label gform-field-label--type-sub '>Pays<\/label>\n                                        <select name='input_11.6' id='input_62_11_6'   aria-required='true'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Afrique du Sud' >Afrique du Sud<\/option><option value='Albanie' >Albanie<\/option><option value='Alg\u00e9rie' >Alg\u00e9rie<\/option><option value='Allemagne' >Allemagne<\/option><option value='Andorre' >Andorre<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctique' >Antarctique<\/option><option value='Antigua-et-Barbuda' >Antigua-et-Barbuda<\/option><option value='Arabie Saoudite' >Arabie Saoudite<\/option><option value='Argentine' >Argentine<\/option><option value='Arm\u00e9nie' >Arm\u00e9nie<\/option><option value='Aruba' >Aruba<\/option><option value='Australie' >Australie<\/option><option value='Autriche' >Autriche<\/option><option value='Azerba\u00efdjan' >Azerba\u00efdjan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahre\u00efn' >Bahre\u00efn<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Belarus' >Belarus<\/option><option value='Belgique' >Belgique<\/option><option value='Belize' >Belize<\/option><option value='Bermudes' >Bermudes<\/option><option value='Bhoutan' >Bhoutan<\/option><option value='Bolivie' >Bolivie<\/option><option value='Bonaire, Saint-Eustache et Saba' >Bonaire, Saint-Eustache et Saba<\/option><option value='Bosnie-Herz\u00e9govine' >Bosnie-Herz\u00e9govine<\/option><option value='Botswana' >Botswana<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Br\u00e9sil' >Br\u00e9sil<\/option><option value='Bulgarie' >Bulgarie<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9nin' >B\u00e9nin<\/option><option value='Cambodge' >Cambodge<\/option><option value='Cameroun' >Cameroun<\/option><option value='Canada' >Canada<\/option><option value='Cap-Vert' >Cap-Vert<\/option><option value='Chili' >Chili<\/option><option value='Chine' >Chine<\/option><option value='Chypre' >Chypre<\/option><option value='Colombie' >Colombie<\/option><option value='Comores' >Comores<\/option><option value='Congo' >Congo<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatie' >Croatie<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d\u2019Ivoire' >C\u00f4te d\u2019Ivoire<\/option><option value='Danemark' >Danemark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominique' >Dominique<\/option><option value='Espagne' >Espagne<\/option><option value='Estonie' >Estonie<\/option><option value='Eswatini' >Eswatini<\/option><option value='Fidji' >Fidji<\/option><option value='Finlande' >Finlande<\/option><option value='France' >France<\/option><option value='Gabon' >Gabon<\/option><option value='Gambie' >Gambie<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Grenade' >Grenade<\/option><option value='Groenland' >Groenland<\/option><option value='Gr\u00e8ce' >Gr\u00e8ce<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernesey' >Guernesey<\/option><option value='Guin\u00e9e' >Guin\u00e9e<\/option><option value='Guin\u00e9e Fran\u00e7aise' >Guin\u00e9e Fran\u00e7aise<\/option><option value='Guin\u00e9e \u00e9quatoriale' >Guin\u00e9e \u00e9quatoriale<\/option><option value='Guin\u00e9e-Bissau' >Guin\u00e9e-Bissau<\/option><option value='Guyane' >Guyane<\/option><option value='G\u00e9orgie' >G\u00e9orgie<\/option><option value='Ha\u00efti' >Ha\u00efti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hongrie' >Hongrie<\/option><option value='Iles Aland' >Iles Aland<\/option><option value='Inde' >Inde<\/option><option value='Indon\u00e9sie' >Indon\u00e9sie<\/option><option value='Irak' >Irak<\/option><option value='Iran' >Iran<\/option><option value='Irlande' >Irlande<\/option><option value='Islande' >Islande<\/option><option value='Isra\u00ebl' >Isra\u00ebl<\/option><option value='Italie' >Italie<\/option><option value='Jama\u00efque' >Jama\u00efque<\/option><option value='Japon' >Japon<\/option><option value='Jersey' >Jersey<\/option><option value='Jordanie' >Jordanie<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kirghizistan' >Kirghizistan<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kowe\u00eft' >Kowe\u00eft<\/option><option value='La Barbade' >La Barbade<\/option><option value='La R\u00e9union' >La R\u00e9union<\/option><option value='Lesotho' >Lesotho<\/option><option value='Lettonie' >Lettonie<\/option><option value='Liban' >Liban<\/option><option value='Liberia' >Liberia<\/option><option value='Libye' >Libye<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituanie' >Lituanie<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malaisie' >Malaisie<\/option><option value='Malawi' >Malawi<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malte' >Malte<\/option><option value='Maroc' >Maroc<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritanie' >Mauritanie<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexique' >Mexique<\/option><option value='Micron\u00e9sie' >Micron\u00e9sie<\/option><option value='Moldavie' >Moldavie<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolie' >Mongolie<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mont\u00e9n\u00e9gro' >Mont\u00e9n\u00e9gro<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibie' >Namibie<\/option><option value='Nauru' >Nauru<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nig\u00e9ria' >Nig\u00e9ria<\/option><option value='Niue' >Niue<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Norv\u00e8ge' >Norv\u00e8ge<\/option><option value='Nouvelle Cal\u00e9donie' >Nouvelle Cal\u00e9donie<\/option><option value='Nouvelle-Z\u00e9lande' >Nouvelle-Z\u00e9lande<\/option><option value='N\u00e9pal' >N\u00e9pal<\/option><option value='Oman' >Oman<\/option><option value='Ouganda' >Ouganda<\/option><option value='Ouzb\u00e9kistan' >Ouzb\u00e9kistan<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Panama' >Panama<\/option><option value='Papouasie-Nouvelle-Guin\u00e9e' >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value='Paraguay' >Paraguay<\/option><option value='Pays-Bas' >Pays-Bas<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Pologne' >Pologne<\/option><option value='Polyn\u00e9sie fran\u00e7aise' >Polyn\u00e9sie fran\u00e7aise<\/option><option value='Porto Rico' >Porto Rico<\/option><option value='Portugal' >Portugal<\/option><option value='P\u00e9rou' >P\u00e9rou<\/option><option value='Qatar' >Qatar<\/option><option value='Roumanie' >Roumanie<\/option><option value='Royaume-Uni' >Royaume-Uni<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9publique Dominicaine' >R\u00e9publique Dominicaine<\/option><option value='R\u00e9publique centrafricaine' >R\u00e9publique centrafricaine<\/option><option value='R\u00e9publique d\u00e9mocratique du Congo' >R\u00e9publique d\u00e9mocratique du Congo<\/option><option value='R\u00e9publique d\u00e9mocratique populaire Lao' >R\u00e9publique d\u00e9mocratique populaire Lao<\/option><option value='Sahara occidental' >Sahara occidental<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint-Christophe-et-Nevis' >Saint-Christophe-et-Nevis<\/option><option value='Saint-Marin' >Saint-Marin<\/option><option value='Saint-Martin' >Saint-Martin<\/option><option value='Saint-Pierre-et-Miquelon' >Saint-Pierre-et-Miquelon<\/option><option value='Saint-Si\u00e8ge' >Saint-Si\u00e8ge<\/option><option value='Saint-Vincent-et-les Grenadines' >Saint-Vincent-et-les Grenadines<\/option><option value='Sainte-Lucie' >Sainte-Lucie<\/option><option value='Salvador' >Salvador<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa am\u00e9ricaines' >Samoa am\u00e9ricaines<\/option><option value='Sao Tom\u00e9 et Principe' >Sao Tom\u00e9 et Principe<\/option><option value='Serbie' >Serbie<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapour' >Singapour<\/option><option value='Slovaquie' >Slovaquie<\/option><option value='Slov\u00e9nie' >Slov\u00e9nie<\/option><option value='Somalie' >Somalie<\/option><option value='Soudan' >Soudan<\/option><option value='Soudan du Sud' >Soudan du Sud<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Suisse' >Suisse<\/option><option value='Suriname' >Suriname<\/option><option value='Su\u00e8de' >Su\u00e8de<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='S\u00e9n\u00e9gal' >S\u00e9n\u00e9gal<\/option><option value='Tadjikistan' >Tadjikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Ta\u00efwan' >Ta\u00efwan<\/option><option value='Tchad' >Tchad<\/option><option value='Terres australes Fran\u00e7aises' >Terres australes Fran\u00e7aises<\/option><option value='Territoire britannique de l&#039;oc\u00e9an Indien' >Territoire britannique de l&#039;oc\u00e9an Indien<\/option><option value='Tha\u00eflande' >Tha\u00eflande<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinit\u00e9 et Tobago' >Trinit\u00e9 et Tobago<\/option><option value='Tunisie' >Tunisie<\/option><option value='Turkm\u00e9nistan' >Turkm\u00e9nistan<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='Ukraine' >Ukraine<\/option><option value='Uruguay' >Uruguay<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Wallis et Futuna' >Wallis et Futuna<\/option><option value='Y\u00e9men' >Y\u00e9men<\/option><option value='Zambie' >Zambie<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c9gypte' >\u00c9gypte<\/option><option value='\u00c9mirats arabes unis' >\u00c9mirats arabes unis<\/option><option value='\u00c9quateur' >\u00c9quateur<\/option><option value='\u00c9rythr\u00e9e' >\u00c9rythr\u00e9e<\/option><option value='\u00c9tat palestinien' >\u00c9tat palestinien<\/option><option value='\u00c9tats-Unis' >\u00c9tats-Unis<\/option><option value='\u00c9thiopie' >\u00c9thiopie<\/option><option value='\u00cele Bouvet' >\u00cele Bouvet<\/option><option value='\u00cele Maurice' >\u00cele Maurice<\/option><option value='\u00cele de Man' >\u00cele de Man<\/option><option value='\u00cele de Norfolk' >\u00cele de Norfolk<\/option><option value='\u00cele de No\u00ebl' >\u00cele de No\u00ebl<\/option><option value='\u00celes Cayman' >\u00celes Cayman<\/option><option value='\u00celes Cocos' >\u00celes Cocos<\/option><option value='\u00celes Cook' >\u00celes Cook<\/option><option value='\u00celes Falkland' >\u00celes Falkland<\/option><option value='\u00celes F\u00e9ro\u00e9' >\u00celes F\u00e9ro\u00e9<\/option><option value='\u00celes Mariannes du Nord' >\u00celes Mariannes du Nord<\/option><option value='\u00celes Marshall' >\u00celes Marshall<\/option><option value='\u00celes Salomon' >\u00celes Salomon<\/option><option value='\u00celes Turques-et-Ca\u00efques' >\u00celes Turques-et-Ca\u00efques<\/option><option value='\u00celes Vierges am\u00e9ricaines' >\u00celes Vierges am\u00e9ricaines<\/option><option value='\u00celes Vierges britanniques' >\u00celes Vierges britanniques<\/option><option value='\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis' >\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option> <\/select>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_62_12\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Debit \/ Credit Card Information<\/h3><\/div><fieldset id=\"field_62_13\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Card Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_62_13'>\n\t\t\t<div class='gchoice gchoice_62_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Mastercard'  id='choice_62_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_62_13_0' id='label_62_13_0' class='gform-field-label gform-field-label--type-inline'>Mastercard<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_62_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Visa'  id='choice_62_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_62_13_1' id='label_62_13_1' class='gform-field-label gform-field-label--type-inline'>Visa<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_62_13_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='American Express'  id='choice_62_13_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_62_13_2' id='label_62_13_2' class='gform-field-label gform-field-label--type-inline'>American Express<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_62_13_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Discovery'  id='choice_62_13_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_62_13_3' id='label_62_13_3' class='gform-field-label gform-field-label--type-inline'>Discovery<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_62_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_62_14'>Card Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_62_14' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_62_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_62_15'>Expiration Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_62_15' type='text' value='' class='medium'    placeholder='mm\/yy' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_62_31\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Is the billing information the same as the customer&#039;s information above?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_62_31'>\n\t\t\t<div class='gchoice gchoice_62_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_62_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_62_31_0' id='label_62_31_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_62_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_62_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_62_31_1' id='label_62_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_62_16\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Debit \/ Credit Card Billing Information<\/h3><\/div><fieldset id=\"field_62_17\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cardholder&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_62_17'>\n                            \n                            <span id='input_62_17_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_62_17_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                    <input type='text' name='input_17.3' id='input_62_17_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_62_17_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_62_17_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                            <input type='text' name='input_17.6' id='input_62_17_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_62_18\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cardholder&#039;s Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_62_18' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_62_18_1_container' >\n                                        <label for='input_62_18_1' id='input_62_18_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                        <input type='text' name='input_18.1' id='input_62_18_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_62_18_2_container' >\n                                        <label for='input_62_18_2' id='input_62_18_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                        <input type='text' name='input_18.2' id='input_62_18_2' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_62_18_3_container' >\n                                    <label for='input_62_18_3' id='input_62_18_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                    <input type='text' name='input_18.3' id='input_62_18_3' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_62_18_4_container' >\n                                        <label for='input_62_18_4' id='input_62_18_4_label' class='gform-field-label gform-field-label--type-sub '>\u00c9tat \/ Province \/ R\u00e9gion<\/label>\n                                        <input type='text' name='input_18.4' id='input_62_18_4' value=''      aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_62_18_5_container' >\n                                    <label for='input_62_18_5' id='input_62_18_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Code postal<\/label>\n                                    <input type='text' name='input_18.5' id='input_62_18_5' value=''    aria-required='true'    \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_62_18_6_container' >\n                                        <label for='input_62_18_6' id='input_62_18_6_label' class='gform-field-label gform-field-label--type-sub '>Pays<\/label>\n                                        <select name='input_18.6' id='input_62_18_6'   aria-required='true'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Afrique du Sud' >Afrique du Sud<\/option><option value='Albanie' >Albanie<\/option><option value='Alg\u00e9rie' >Alg\u00e9rie<\/option><option value='Allemagne' >Allemagne<\/option><option value='Andorre' >Andorre<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctique' >Antarctique<\/option><option value='Antigua-et-Barbuda' >Antigua-et-Barbuda<\/option><option value='Arabie Saoudite' >Arabie Saoudite<\/option><option value='Argentine' >Argentine<\/option><option value='Arm\u00e9nie' >Arm\u00e9nie<\/option><option value='Aruba' >Aruba<\/option><option value='Australie' >Australie<\/option><option value='Autriche' >Autriche<\/option><option value='Azerba\u00efdjan' >Azerba\u00efdjan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahre\u00efn' >Bahre\u00efn<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Belarus' >Belarus<\/option><option value='Belgique' >Belgique<\/option><option value='Belize' >Belize<\/option><option value='Bermudes' >Bermudes<\/option><option value='Bhoutan' >Bhoutan<\/option><option value='Bolivie' >Bolivie<\/option><option value='Bonaire, Saint-Eustache et Saba' >Bonaire, Saint-Eustache et Saba<\/option><option value='Bosnie-Herz\u00e9govine' >Bosnie-Herz\u00e9govine<\/option><option value='Botswana' >Botswana<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Br\u00e9sil' >Br\u00e9sil<\/option><option value='Bulgarie' >Bulgarie<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9nin' >B\u00e9nin<\/option><option value='Cambodge' >Cambodge<\/option><option value='Cameroun' >Cameroun<\/option><option value='Canada' >Canada<\/option><option value='Cap-Vert' >Cap-Vert<\/option><option value='Chili' >Chili<\/option><option value='Chine' >Chine<\/option><option value='Chypre' >Chypre<\/option><option value='Colombie' >Colombie<\/option><option value='Comores' >Comores<\/option><option value='Congo' >Congo<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatie' >Croatie<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d\u2019Ivoire' >C\u00f4te d\u2019Ivoire<\/option><option value='Danemark' >Danemark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominique' >Dominique<\/option><option value='Espagne' >Espagne<\/option><option value='Estonie' >Estonie<\/option><option value='Eswatini' >Eswatini<\/option><option value='Fidji' >Fidji<\/option><option value='Finlande' >Finlande<\/option><option value='France' >France<\/option><option value='Gabon' >Gabon<\/option><option value='Gambie' >Gambie<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Grenade' >Grenade<\/option><option value='Groenland' >Groenland<\/option><option value='Gr\u00e8ce' >Gr\u00e8ce<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernesey' >Guernesey<\/option><option value='Guin\u00e9e' >Guin\u00e9e<\/option><option value='Guin\u00e9e Fran\u00e7aise' >Guin\u00e9e Fran\u00e7aise<\/option><option value='Guin\u00e9e \u00e9quatoriale' >Guin\u00e9e \u00e9quatoriale<\/option><option value='Guin\u00e9e-Bissau' >Guin\u00e9e-Bissau<\/option><option value='Guyane' >Guyane<\/option><option value='G\u00e9orgie' >G\u00e9orgie<\/option><option value='Ha\u00efti' >Ha\u00efti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hongrie' >Hongrie<\/option><option value='Iles Aland' >Iles Aland<\/option><option value='Inde' >Inde<\/option><option value='Indon\u00e9sie' >Indon\u00e9sie<\/option><option value='Irak' >Irak<\/option><option value='Iran' >Iran<\/option><option value='Irlande' >Irlande<\/option><option value='Islande' >Islande<\/option><option value='Isra\u00ebl' >Isra\u00ebl<\/option><option value='Italie' >Italie<\/option><option value='Jama\u00efque' >Jama\u00efque<\/option><option value='Japon' >Japon<\/option><option value='Jersey' >Jersey<\/option><option value='Jordanie' >Jordanie<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kirghizistan' >Kirghizistan<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kowe\u00eft' >Kowe\u00eft<\/option><option value='La Barbade' >La Barbade<\/option><option value='La R\u00e9union' >La R\u00e9union<\/option><option value='Lesotho' >Lesotho<\/option><option value='Lettonie' >Lettonie<\/option><option value='Liban' >Liban<\/option><option value='Liberia' >Liberia<\/option><option value='Libye' >Libye<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituanie' >Lituanie<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malaisie' >Malaisie<\/option><option value='Malawi' >Malawi<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malte' >Malte<\/option><option value='Maroc' >Maroc<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritanie' >Mauritanie<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexique' >Mexique<\/option><option value='Micron\u00e9sie' >Micron\u00e9sie<\/option><option value='Moldavie' >Moldavie<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolie' >Mongolie<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mont\u00e9n\u00e9gro' >Mont\u00e9n\u00e9gro<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibie' >Namibie<\/option><option value='Nauru' >Nauru<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nig\u00e9ria' >Nig\u00e9ria<\/option><option value='Niue' >Niue<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Norv\u00e8ge' >Norv\u00e8ge<\/option><option value='Nouvelle Cal\u00e9donie' >Nouvelle Cal\u00e9donie<\/option><option value='Nouvelle-Z\u00e9lande' >Nouvelle-Z\u00e9lande<\/option><option value='N\u00e9pal' >N\u00e9pal<\/option><option value='Oman' >Oman<\/option><option value='Ouganda' >Ouganda<\/option><option value='Ouzb\u00e9kistan' >Ouzb\u00e9kistan<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Panama' >Panama<\/option><option value='Papouasie-Nouvelle-Guin\u00e9e' >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value='Paraguay' >Paraguay<\/option><option value='Pays-Bas' >Pays-Bas<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Pologne' >Pologne<\/option><option value='Polyn\u00e9sie fran\u00e7aise' >Polyn\u00e9sie fran\u00e7aise<\/option><option value='Porto Rico' >Porto Rico<\/option><option value='Portugal' >Portugal<\/option><option value='P\u00e9rou' >P\u00e9rou<\/option><option value='Qatar' >Qatar<\/option><option value='Roumanie' >Roumanie<\/option><option value='Royaume-Uni' >Royaume-Uni<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9publique Dominicaine' >R\u00e9publique Dominicaine<\/option><option value='R\u00e9publique centrafricaine' >R\u00e9publique centrafricaine<\/option><option value='R\u00e9publique d\u00e9mocratique du Congo' >R\u00e9publique d\u00e9mocratique du Congo<\/option><option value='R\u00e9publique d\u00e9mocratique populaire Lao' >R\u00e9publique d\u00e9mocratique populaire Lao<\/option><option value='Sahara occidental' >Sahara occidental<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint-Christophe-et-Nevis' >Saint-Christophe-et-Nevis<\/option><option value='Saint-Marin' >Saint-Marin<\/option><option value='Saint-Martin' >Saint-Martin<\/option><option value='Saint-Pierre-et-Miquelon' >Saint-Pierre-et-Miquelon<\/option><option value='Saint-Si\u00e8ge' >Saint-Si\u00e8ge<\/option><option value='Saint-Vincent-et-les Grenadines' >Saint-Vincent-et-les Grenadines<\/option><option value='Sainte-Lucie' >Sainte-Lucie<\/option><option value='Salvador' >Salvador<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa am\u00e9ricaines' >Samoa am\u00e9ricaines<\/option><option value='Sao Tom\u00e9 et Principe' >Sao Tom\u00e9 et Principe<\/option><option value='Serbie' >Serbie<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapour' >Singapour<\/option><option value='Slovaquie' >Slovaquie<\/option><option value='Slov\u00e9nie' >Slov\u00e9nie<\/option><option value='Somalie' >Somalie<\/option><option value='Soudan' >Soudan<\/option><option value='Soudan du Sud' >Soudan du Sud<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Suisse' >Suisse<\/option><option value='Suriname' >Suriname<\/option><option value='Su\u00e8de' >Su\u00e8de<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='S\u00e9n\u00e9gal' >S\u00e9n\u00e9gal<\/option><option value='Tadjikistan' >Tadjikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Ta\u00efwan' >Ta\u00efwan<\/option><option value='Tchad' >Tchad<\/option><option value='Terres australes Fran\u00e7aises' >Terres australes Fran\u00e7aises<\/option><option value='Territoire britannique de l&#039;oc\u00e9an Indien' >Territoire britannique de l&#039;oc\u00e9an Indien<\/option><option value='Tha\u00eflande' >Tha\u00eflande<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinit\u00e9 et Tobago' >Trinit\u00e9 et Tobago<\/option><option value='Tunisie' >Tunisie<\/option><option value='Turkm\u00e9nistan' >Turkm\u00e9nistan<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='Ukraine' >Ukraine<\/option><option value='Uruguay' >Uruguay<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Wallis et Futuna' >Wallis et Futuna<\/option><option value='Y\u00e9men' >Y\u00e9men<\/option><option value='Zambie' >Zambie<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c9gypte' >\u00c9gypte<\/option><option value='\u00c9mirats arabes unis' >\u00c9mirats arabes unis<\/option><option value='\u00c9quateur' >\u00c9quateur<\/option><option value='\u00c9rythr\u00e9e' >\u00c9rythr\u00e9e<\/option><option value='\u00c9tat palestinien' >\u00c9tat palestinien<\/option><option value='\u00c9tats-Unis' >\u00c9tats-Unis<\/option><option value='\u00c9thiopie' >\u00c9thiopie<\/option><option value='\u00cele Bouvet' >\u00cele Bouvet<\/option><option value='\u00cele Maurice' >\u00cele Maurice<\/option><option value='\u00cele de Man' >\u00cele de Man<\/option><option value='\u00cele de Norfolk' >\u00cele de Norfolk<\/option><option value='\u00cele de No\u00ebl' >\u00cele de No\u00ebl<\/option><option value='\u00celes Cayman' >\u00celes Cayman<\/option><option value='\u00celes Cocos' >\u00celes Cocos<\/option><option value='\u00celes Cook' >\u00celes Cook<\/option><option value='\u00celes Falkland' >\u00celes Falkland<\/option><option value='\u00celes F\u00e9ro\u00e9' >\u00celes F\u00e9ro\u00e9<\/option><option value='\u00celes Mariannes du Nord' >\u00celes Mariannes du Nord<\/option><option value='\u00celes Marshall' >\u00celes Marshall<\/option><option value='\u00celes Salomon' >\u00celes Salomon<\/option><option value='\u00celes Turques-et-Ca\u00efques' >\u00celes Turques-et-Ca\u00efques<\/option><option value='\u00celes Vierges am\u00e9ricaines' >\u00celes Vierges am\u00e9ricaines<\/option><option value='\u00celes Vierges britanniques' >\u00celes Vierges britanniques<\/option><option value='\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis' >\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option> <\/select>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_62_19\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_62_19'>Cardholder&#039;s Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_19' id='input_62_19' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_62_20\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_62_20'>Cardholder&#039;s Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_20' id='input_62_20' type='email' value='' class='large'   placeholder='example@company.com' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_62_21\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">MFE Credit Card Authorization<\/h3><\/div><fieldset id=\"field_62_22\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >You, the undersigned, hereby authorize MFE Inspection Solutions to initiate (check all that apply):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_62_22'><div class='gchoice gchoice_62_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='a one time fee (insert fee amount below)'  id='choice_62_22_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_62_22_1' id='label_62_22_1' class='gform-field-label gform-field-label--type-inline'>a one time fee (insert fee amount below)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_62_22_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.2' type='checkbox'  value='automated charges of the above identified debit and\/or credit card up to 150% of the new retail value of the \u201cRented Item(s)\u201d identified in each \u201cRental Contract\u201d (as identified below); and\/or'  id='choice_62_22_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_62_22_2' id='label_62_22_2' class='gform-field-label gform-field-label--type-inline'>automated charges of the above identified debit and\/or credit card up to 150% of the new retail value of the \u201cRented Item(s)\u201d identified in each \u201cRental Contract\u201d (as identified below); and\/or<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_62_22_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.3' type='checkbox'  value='all other and\/or future charges authorized by persons MFE reasonably believes to be your employees, including the following SPECIFICALLY NAMED INDIVIDUALS AUTHORIZED TO CHARGE THE ABOVE CARD:'  id='choice_62_22_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_62_22_3' id='label_62_22_3' class='gform-field-label gform-field-label--type-inline'>all other and\/or future charges authorized by persons MFE reasonably believes to be your employees, including the following SPECIFICALLY NAMED INDIVIDUALS AUTHORIZED TO CHARGE THE ABOVE CARD:<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_62_23\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_62_23'>One Time Fee Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_23' id='input_62_23' type='text' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_62_24\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Authorized Party Name(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_62_24'>If more than one person is listed, collectively, the \u201cAuthorized Parties.\u201d <\/div><div class='ginput_container ginput_container_list ginput_list '><div class='gfield_list gfield_list_container'><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_24_cell1 gform-grid-col' ><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_62_24\" aria-label='Authorized Party Name(s), Row 1' data-aria-label-template='Authorized Party Name(s), Row {0}' type='text' name='input_24[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Ajouter une autre ligne' onclick='gformAddListItem(this, 0)'>Ajouter<\/button>   <button type='button'  class='delete_list_item' aria-label='Supprimer la ligne 1' data-aria-label-template='Supprimer la ligne {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_62_25\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><div class='gsection_description' id='gfield_description_62_25'>To the maximum extent permitted under applicable law, you hereby authorize MFE Inspection Solutions to bill to the above identified debit\/credit card(s) all charges, known or unknown, accrued or unaccrued (including without limitation, all rent and overtime, as well as all charges for delivery, installation, maintenance, repair, replacement, removal, retrieval, cleaning, packing, refueling [including all fuel required therefor], taxes, tolls, fines, fees, assessments, attorneys\u2019 fees, collection costs and costs of court) due and coming due in connection with any and all rentals of personal property (each, a \u201cRented Item\u201d) from MFE Inspection Solutions to you, the above identified Customer and\/or the above named Authorized Party(ies) (each, a \u201cRental\u201d) up to an amount equal to 150% of the new retail price of each such Rented Item, plus all associated interchange and other card acceptance fees (the \u201cAuthorized Amount\u201d). You acknowledge that: (a) each Rental will be subject to the terms of each Rental Contract and\/or Master Rental Agreement you have entered into with MFE Inspection Solutions (each being referred to herein as a \u201cRental Contract\u201d and incorporated herein); and (b) you have received written notice of the new retail price of each Rented Item. Accordingly, you irrevocably and unconditionally waive any and all claims, setoffs, chargebacks and counterclaims with respect to the above referenced charges. Additionally, to the maximum extent permitted under applicable law, you hereby: (i) authorize MFE Inspection Solutions to: (A) retain a complete copy of your debit\/credit card(s) and all information included thereon until this Authorization is revoked or terminated as provided below; (B) submit for payment on each such card all of the above referenced charges (including the Authorized Amount), without additional notice to, or signature or authorization by, you; (ii) make, constitute and appoint MFE Inspection Solutions as your agent and attorney-in-fact to execute and deliver, in your name, place and stead, all authorizations that may hereafter be required by any third party(ies), including card issuers and merchant services providers, in order to give full effect to this Authorization (such power being durable, coupled with an interest, and not affected by your disability); and (iii) release and discharge, and agree to indemnify, defend and hold harmless MFE Inspection Solutions, its agents and employees, for, from and against all liabilities, claims, damages, losses, costs and expenses (including attorneys\u2019 fees) arising from or in connection with the foregoing and\/or any declination or reversal of such charge(s). This Authorization supplements each Rental Contract, and will remain in effect with respect to you, the Customer, and each of the above referenced Authorized Parties until the last to terminate of all current and future Rentals, and thereafter until MFE has received written notice of the undersigned\u2019s revocation or termination hereof, at such time and in such manner as may be necessary in order to afford MFE Inspection Solutions a reasonable opportunity to act upon such notice. You, the undersigned, hereby: (a) agree to take such actions as may be necessary or appropriate in order to give full effect to the terms of this Authorization; and (b) PERSONALLY GUARANTEE the prompt payment and performance of all obligations now or hereafter owing to MFE Inspection Solutions under and\/or in connection with this Authorization, each Rental and each Rental Contract (or any of them).<\/div><\/div><div id=\"field_62_26\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_62_26'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_62_26' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_62_29\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_62_29'>Today&#039;s Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_62_29' type='text' value='' class='medium'    placeholder='mm\/dd\/yyyy' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_62_28\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Authorization Acknowledgment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_62_28'><div class='gchoice gchoice_62_28_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.1' type='checkbox'  value='By typing your name in the box above, you acknowledge and agree that your typed name constitutes your electronic signature. You understand and consent that this electronic signature has the same legal effect as a handwritten signature for the purposes of this credit card authorization agreement.'  id='choice_62_28_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_62_28_1' id='label_62_28_1' class='gform-field-label gform-field-label--type-inline'>By typing your name in the box above, you acknowledge and agree that your typed name constitutes your electronic signature. 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