<div class="page_header page_header_has_title">
<div class="page_header_inner">
<div class="page_breadcrumb">
<div class="fs-row">
<div class="fs-cell">
<div class="page_breadcrumb_inner">
<div class="breadcrumb">
<nav class="breadcrumb_nav" aria-labelledby="breadcrumb_nav_title">
<div class="breadcrumb_nav_header">
<h2 class="breadcrumb_nav_title" id="breadcrumb_nav_title">You are here:</h2>
</div>
<ol class="breadcrumb_list" aria-labelledby="breadcrumb_nav_title">
<li class="breadcrumb_item breadcrumb_item_home">
<a class="breadcrumb_pill breadcrumb_pill_link" href="page-home.html">
<span class="breadcrumb_pill_inner">
<span class="breadcrumb_pill_label">Home</span>
</span>
</a>
<span class="breadcrumb_divider" aria-hidden="true">
<svg class="icon icon_forward_slash">
<use href="/images/icons.svg#forward_slash" />
</svg>
</span>
</li>
<li class="breadcrumb_item">
<a class="breadcrumb_pill breadcrumb_pill_link" href="#">
<span class="breadcrumb_pill_inner">
<span class="breadcrumb_pill_label">Navigation Level</span>
</span>
</a>
<span class="breadcrumb_divider" aria-hidden="true">
<svg class="icon icon_forward_slash">
<use href="/images/icons.svg#forward_slash" />
</svg>
</span>
</li>
<li class="breadcrumb_item">
<a class="breadcrumb_pill breadcrumb_pill_link" href="#">
<span class="breadcrumb_pill_inner">
<span class="breadcrumb_pill_label">Parent Level</span>
</span>
</a>
<span class="breadcrumb_divider" aria-hidden="true">
<svg class="icon icon_forward_slash">
<use href="/images/icons.svg#forward_slash" />
</svg>
</span>
</li>
<li class="breadcrumb_item">
<span class="breadcrumb_pill">
<span class="breadcrumb_pill_inner">
<span class="breadcrumb_pill_label">Make a Payment</span>
</span>
</span>
<span class="breadcrumb_end" aria-hidden="true">
<svg class="icon icon_forward_slash">
<use href="/images/icons.svg#forward_slash" />
</svg>
</span>
</li>
</ol>
</nav>
</div>
</div>
</div>
</div>
</div>
<div class="page_intro">
<div class="fs-row">
<div class="fs-cell fs-lg-10 fs-xl-9">
<div class="page_intro_inner">
<h1 class="page_title" id="page_title" tabindex="-1">Make a Payment</h1>
<p class="page_description">Lorem ipsum dolor sit amet, consectetur adipiscing elit. Phasellus egestas nibh rhoncus, pulvinar purus eget, sagittis felis.</p>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="page_content" id="page_content" tabindex="-1" aria-labelledby="page_title">
<div class="fs-row">
<div class="fs-cell">
<div class="page_content_inner">
<div class="wysiwyg_block">
<!-- WYSIWYG -->
<div class="typography">
<p>Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. Aenean massa. Cum sociis natoque penatibus et magnis dis parturient montes, nascetur ridiculus mus. Donec quam felis, ultricies nec, pellentesque eu, pretium quis, sem. Nulla consequat massa quis enim. Donec pede justo, fringilla vel, aliquet nec, vulputate eget, arcu.</p>
<p>In enim justo, rhoncus ut, imperdiet a, venenatis vitae, justo. Nullam dictum felis eu pede mollis pretium. Integer tincidunt. Cras dapibus. Vivamus elementum semper nisi. Aenean vulputate eleifend tellus. Aenean leo ligula, porttitor eu, consequat vitae, eleifend ac, enim. Aliquam lorem ante, dapibus in, viverra quis, feugiat a, tellus. Phasellus viverra nulla ut metus varius laoreet. Quisque rutrum.</p>
<form class="generic_form" id="js-make-a-payment-form" method="post" action="#">
<h2>
Driver Information
</h2>
<p>
PLEASE READ: Enter your PERNR (which appears in E210 or on the upper-right corner of your paycheck).
</p>
<label>
First Name <span class="form_required_star">*</span>
<input autocomplete="given-name" type="text" name="FIRSTNAME" value="" required />
</label>
<label>
Last Name <span class="form_required_star">*</span>
<input autocomplete="family-name" type="text" name="LASTNAME" value="" required />
</label>
<label>
PERNR
<input type="text" name="PERNR" value="" />
</label>
<label>
Primary Phone <span class="form_required_star">*</span>
<input autocomplete="tel" type="tel" name="PRIMARYPHONE" value="" required />
</label>
<label>
Email <span class="form_required_star">*</span>
<input autocomplete="email" type="email" name="EMAIL" value="" required />
</label>
<h2>
Vehicle Information
</h2>
<label>
Make <span class="form_required_star">*</span>
<input type="text" name="MAKE" value="" required />
</label>
<label>
Model <span class="form_required_star">*</span>
<input type="text" name="MODEL" value="" required />
</label>
<label>
License Plate <span class="form_required_star">*</span>
<input type="text" name="LICENSEPLATE" value="" required />
</label>
<label>
State <span class="form_required_star">*</span>
<select name="STATE" required>
<option value="">-- Select from the following --</option>
</select>
</label>
<h2>Payment Details</h2>
<label>
Payment Request <span class="form_required_star">*</span>
<select class="js-make-a-payment-request" name="paymentRequest" required>
<option value="Citation Payment">Citation Payment</option>
<option value="Additional Payment for Permit">Additional Payment for Permit</option>
<option value="Other">Other</option>
</select>
</label>
<div class="js-make-a-payment-other" style="display: none;">
<label>
Additional Details <span class="form_required_star">*</span>
<input type="text" name="additionalDetails" value="" />
</label>
</div>
<label>
Citation Number
<input type="text" name="citationNumber" value="" />
</label>
<label>
Payment Amount <span class="form_required_star">*</span>
<input type="text" name="paymentAmount" value="" required />
</label>
<input type="submit" value="Submit Request" />
</form>
</div>
<!-- END: WYSIWYG -->
</div>
</div>
</div>
</div>
</div>
{% include '@partial-page-header' with {
page: page
} %}
<div class="page_content" id="page_content" tabindex="-1" aria-labelledby="page_title">
<div class="fs-row">
<div class="fs-cell">
<div class="page_content_inner">
<div class="wysiwyg_block">
<!-- WYSIWYG -->
<div class="typography">
<p>Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. Aenean massa. Cum sociis natoque penatibus et magnis dis parturient montes, nascetur ridiculus mus. Donec quam felis, ultricies nec, pellentesque eu, pretium quis, sem. Nulla consequat massa quis enim. Donec pede justo, fringilla vel, aliquet nec, vulputate eget, arcu.</p>
<p>In enim justo, rhoncus ut, imperdiet a, venenatis vitae, justo. Nullam dictum felis eu pede mollis pretium. Integer tincidunt. Cras dapibus. Vivamus elementum semper nisi. Aenean vulputate eleifend tellus. Aenean leo ligula, porttitor eu, consequat vitae, eleifend ac, enim. Aliquam lorem ante, dapibus in, viverra quis, feugiat a, tellus. Phasellus viverra nulla ut metus varius laoreet. Quisque rutrum.</p>
<form class="generic_form" id="js-make-a-payment-form" method="post" action="#">
<h2>
Driver Information
</h2>
<p>
PLEASE READ: Enter your PERNR (which appears in E210 or on the upper-right corner of your paycheck).
</p>
<label>
First Name <span class="form_required_star">*</span>
<input autocomplete="given-name" type="text" name="FIRSTNAME" value="" required />
</label>
<label>
Last Name <span class="form_required_star">*</span>
<input autocomplete="family-name" type="text" name="LASTNAME" value="" required />
</label>
<label>
PERNR
<input type="text" name="PERNR" value="" />
</label>
<label>
Primary Phone <span class="form_required_star">*</span>
<input autocomplete="tel" type="tel" name="PRIMARYPHONE" value="" required />
</label>
<label>
Email <span class="form_required_star">*</span>
<input autocomplete="email" type="email" name="EMAIL" value="" required />
</label>
<h2>
Vehicle Information
</h2>
<label>
Make <span class="form_required_star">*</span>
<input type="text" name="MAKE" value="" required />
</label>
<label>
Model <span class="form_required_star">*</span>
<input type="text" name="MODEL" value="" required />
</label>
<label>
License Plate <span class="form_required_star">*</span>
<input type="text" name="LICENSEPLATE" value="" required/>
</label>
<label>
State <span class="form_required_star">*</span>
<select name="STATE" required>
<option value="">-- Select from the following --</option>
</select>
</label>
<h2>Payment Details</h2>
<label>
Payment Request <span class="form_required_star">*</span>
<select class="js-make-a-payment-request" name="paymentRequest" required>
<option value="Citation Payment">Citation Payment</option>
<option value="Additional Payment for Permit">Additional Payment for Permit</option>
<option value="Other">Other</option>
</select>
</label>
<div class="js-make-a-payment-other" style="display: none;">
<label>
Additional Details <span class="form_required_star">*</span>
<input type="text" name="additionalDetails" value="" />
</label>
</div>
<label>
Citation Number
<input type="text" name="citationNumber" value="" />
</label>
<label>
Payment Amount <span class="form_required_star">*</span>
<input type="text" name="paymentAmount" value="" required />
</label>
<input type="submit" value="Submit Request" />
</form>
</div>
<!-- END: WYSIWYG -->
</div>
</div>
</div>
</div>
</div>
No notes defined.