Approved
Name:
Amount:
Card Type:
Card Number:
Authcode:
AVS Result:
CVV Result:
OK
OK
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Franklin Grove Living & Rehab
502 North State Street • Franklin Grove, IL 61031
Personal Information
Full Name
*
Address
Zip code
*
Phone Number
Email Address
*
Transaction Details
$
Amount
*
+ Convenience fee
Final Amount
Resident Name
Credit Card Details
Pay with Check
Card Number
*
MMYY
*
CVV
?
Process Payment
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Credit & Debit Processing | Electronic Check Services | Gift & Loyalty Programs | Customized POS Solutions
Franklin Grove Living & Rehab
502 North State Street
Franklin Grove, IL 61031
Tell: 847-982-2300
[response]
ID #[transid]
[created]
[cardholder]
$ [amount]
[cardtype] [ccnum4]
Authorization Number
[authcode]
AVS Response
[avsresult]
CVV response
[cvcresult]
[otherTransaction]
