Approved
Name:
Amount:
Card Type:
Card Number:
Authcode:
AVS Result:
CVV Result:
OK
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Southport Center For Nursing And Rehab
930 Mill Hill Terrace • Southport, CT 06890
Personal Information
Full Name
*
Address
Zip code
Phone Number
Email Address
*
Transaction Details
$
Amount
*
Description
Credit Card Details
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Card Number
*
MMYY
*
CVV
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Credit & Debit Processing | Electronic Check Services | Gift & Loyalty Programs | Customized POS Solutions
Southport Center For Nursing And Rehab
930 Mill Hill Terrace
Southport, CT 06890
Tell: (877) 942 - 4558
[response]
ID #[transid]
[created]
[cardholder]
[amount]
[cardtype] [ccnum4]
Authorization Number
[authcode]
AVS Response
[avsresult]
CVV response
[cvcresult]
