<% ' FP_ASP ASP Automatically generated by a Frontpage Component. Do not Edit. On Error Resume Next Session("FP_OldCodePage") = Session.CodePage Session("FP_OldLCID") = Session.LCID Session.CodePage = 1252 Err.Clear strErrorUrl = "" If Request.ServerVariables("REQUEST_METHOD") = "POST" Then If Request.Form("VTI-GROUP") = "0" Then Err.Clear Set fp_conn = Server.CreateObject("ADODB.Connection") FP_DumpError strErrorUrl, "Cannot create connection" Set fp_rs = Server.CreateObject("ADODB.Recordset") FP_DumpError strErrorUrl, "Cannot create record set" fp_conn.Open Application("PayOnline_ConnectionString") FP_DumpError strErrorUrl, "Cannot open database" fp_rs.Open "Results", fp_conn, 1, 3, 2 ' adOpenKeySet, adLockOptimistic, adCmdTable FP_DumpError strErrorUrl, "Cannot open record set" fp_rs.AddNew FP_DumpError strErrorUrl, "Cannot add new record set to the database" Dim arFormFields0(12) Dim arFormDBFields0(12) Dim arFormValues0(12) arFormFields0(0) = "Social_Securty_Number" arFormDBFields0(0) = "Social_Securty_Number" arFormValues0(0) = Request("Social_Securty_Number") arFormFields0(1) = "CCNum" arFormDBFields0(1) = "CCNum" arFormValues0(1) = Request("CCNum") arFormFields0(2) = "CreditCard" arFormDBFields0(2) = "CreditCard" arFormValues0(2) = Request("CreditCard") arFormFields0(3) = "Expiration_Date" arFormDBFields0(3) = "Expiration_Date" arFormValues0(3) = Request("Expiration_Date") arFormFields0(4) = "Email" arFormDBFields0(4) = "Email" arFormValues0(4) = Request("Email") arFormFields0(5) = "City" arFormDBFields0(5) = "City" arFormValues0(5) = Request("City") arFormFields0(6) = "Name" arFormDBFields0(6) = "Name" arFormValues0(6) = Request("Name") arFormFields0(7) = "CMS_Account_Number" arFormDBFields0(7) = "CMS_Account_Number" arFormValues0(7) = Request("CMS_Account_Number") arFormFields0(8) = "Zip" arFormDBFields0(8) = "Zip" arFormValues0(8) = Request("Zip") arFormFields0(9) = "Payment_Amount" arFormDBFields0(9) = "Payment_Amount" arFormValues0(9) = Request("Payment_Amount") arFormFields0(10) = "Address" arFormDBFields0(10) = "Address" arFormValues0(10) = Request("Address") arFormFields0(11) = "State" arFormDBFields0(11) = "State" arFormValues0(11) = Request("State") FP_SaveFormFields fp_rs, arFormFields0, arFormDBFields0 If Request.ServerVariables("REMOTE_HOST") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("REMOTE_HOST"), "Remote_computer_name" End If If Request.ServerVariables("HTTP_USER_AGENT") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("HTTP_USER_AGENT"), "Browser_type" End If FP_SaveFieldToDB fp_rs, Now, "Timestamp" If Request.ServerVariables("REMOTE_USER") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("REMOTE_USER"), "User_name" End If fp_rs.Update FP_DumpError strErrorUrl, "Cannot update the database" fp_rs.Close fp_conn.Close FP_FormConfirmation "text/html; charset=windows-1252",_ "Form Confirmation",_ "Thank you for submitting the following information:",_ "PayOnline.htm",_ "Return to the form." End If End If Session.CodePage = Session("FP_OldCodePage") Session.LCID = Session("FP_OldLCID") %> Credit Management Services

Credit Management Services of Georgia, LLC

Pay Online Form
 

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Please complete the following information. We will email a receipt.

Name:Email:

Address:

City:State:Zip:

CMS Account Number:SS#:

Card Number:Expiration Date:

Payment Amount:$

 

"Let no debt remain unpaid except the continuing debt to love one another." romans 13:8