Rainier Associates Credit/Debit Card Processing Gateway

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Card Type
Name On Card
Error: Please enter a name.
Card Number
Error: Please enter a valid credit card number.
Security Code
Error: Please enter a security code.
Expiration Date mm/dd/year
Error: Please enter a valid date.
Billing Address
Error: Please enter a valid billing address.
Billing Address Line 2
City
Error: Please enter a city.
State
Error: Please enter a valid state.
Zip
Error: Please enter a valid zip code.
Patient
Error: Please enter patient's name.
Amount
Error: Please enter an amount.