{"id":1719,"date":"2016-01-08T04:37:22","date_gmt":"2016-01-08T12:37:22","guid":{"rendered":"http:\/\/www.breining.edu\/?page_id=1719"},"modified":"2020-02-29T12:14:56","modified_gmt":"2020-02-29T20:14:56","slug":"dui-program-payment","status":"publish","type":"page","link":"https:\/\/www.breining.edu\/index.php\/programsservices\/dui-schools\/dui-program-payment\/","title":{"rendered":"DUI Program Payment"},"content":{"rendered":"<form method=\"post\" enctype=\"multipart\/form-data\" id=\"vfbp-form-40\" class=\"vfbp-form\"><div style=\"display:none;\"><label for=\"vfbp-EMAIL-AN8fuQyoDLXem\">If you are human, leave this field blank.<\/label><input size=\"25\" autocomplete=\"off\" type=\"text\" name=\"vfbp-EMAIL-AN8fuQyoDLXem\" value=\"\" id=\"\"><\/div><input type=\"hidden\" name=\"_vfb-timestamp-40\" value=\"1777545200\" id=\"\"><input type=\"hidden\" name=\"_vfb-form-id\" value=\"40\" id=\"\"><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField959\"><div class=\"vfb-form-group\"><label for=\"vfb-field-959\" class=\"vfb-control-label\">Instructions<\/label><div class=\"\"><p>You may submit a credit card payment for the DUI Program in which you are or were enrolled, using this form.<\/p>\n<p>You will be automatically sent an email confirming this submission, to the email address that is included in this form, once you have selected the &#8220;Submit&#8221; button.<\/p>\n<p>We will process this payment as soon as possible, typically within one business day.<\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Section 1: Client Information<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField960\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField961\"><div class=\"vfb-form-group\"><label for=\"vfb-field-961\" class=\"vfb-control-label\">Full Name: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-961\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-961\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField962\"><div class=\"vfb-form-group\"><label for=\"vfb-field-962\" class=\"vfb-control-label\">Email Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-962\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"email\" name=\"vfb-field-962\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField963\"><div class=\"vfb-form-group\"><label for=\"vfb-field-963\" class=\"vfb-control-label\">Confirm Email Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-963\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"email\" name=\"vfb-field-963\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-phone\" id=\"vfbField964\"><div class=\"vfb-form-group\"><label for=\"vfb-field-964\" class=\"vfb-control-label\">Primary Phone Number <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-964\" class=\"vfb-form-control vfb-intl-phone\" placeholder=\"\" required=\"required\" type=\"tel\" name=\"vfb-field-964\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Section 2: Program Information<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField965\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField966\"><label for=\"vfb-field-966\" class=\"vfb-control-label\">Identify which Sacramento County Breining Institute DUI Program location you are or were attending: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-966-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-966\" required=\"required\" type=\"checkbox\" name=\"vfb-field-966[0]\" value=\"1\">NORTH COUNTY: 8894 Greenback Lane, Orangevale<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-966-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-966\" type=\"checkbox\" name=\"vfb-field-966[1]\" value=\"1\">FOLSOM: 2360 E. Bidwell Street, Suite 107, Folsom<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-966-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-966\" type=\"checkbox\" name=\"vfb-field-966[2]\" value=\"1\">MID-COUNTY: 2775 Cottage Way, Suite 25, Sacramento<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-966-3\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-966\" type=\"checkbox\" name=\"vfb-field-966[3]\" value=\"1\">SOUTH COUNTY: 3159 Dwight Road, Suite 100, Elk Grove<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField968\"><label for=\"vfb-field-968\" class=\"vfb-control-label\">Identify which of the following programs you are or were attending:<\/label><div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-968-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-968\" type=\"checkbox\" name=\"vfb-field-968[0]\" value=\"1\">Wet Reckless program<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-968-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-968\" type=\"checkbox\" name=\"vfb-field-968[1]\" value=\"1\">3 month program<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-968-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-968\" type=\"checkbox\" name=\"vfb-field-968[2]\" value=\"1\">6 month program<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-968-3\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-968\" type=\"checkbox\" name=\"vfb-field-968[3]\" value=\"1\">9 month program<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-968-4\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-968\" type=\"checkbox\" name=\"vfb-field-968[4]\" value=\"1\">Other (or I am not sure which program)<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Section 3: Payment Information<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField972\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-textarea\" id=\"vfbField973\"><div class=\"vfb-form-group\"><label for=\"vfb-field-973\" class=\"vfb-control-label\">Please itemize and explain your payment here:<\/label><div><span class=\"vfb-help-block\">Include the total payment amount that you want to be charged to your credit card.<\/span><textarea id=\"vfb-field-973\" class=\"vfb-form-control\" placeholder=\"\" rows=\"10\" name=\"vfb-field-973\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Section 4: Credit Card Information<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField974\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField975\"><div class=\"vfb-form-group\"><label for=\"vfb-field-975\" class=\"vfb-control-label\">You give permission to and authorize Breining Institute to charge the total amount of the items identified in Section 3, to the following credit card:<\/label><div class=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField976\"><label for=\"vfb-field-976\" class=\"vfb-control-label\">Credit Card: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-radio\"><label><input id=\"vfb-field-976-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-976\" value=\"VISA\">VISA<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-976-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-976\" value=\"MasterCard\">MasterCard<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-976-2\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-976\" value=\"Discover\">Discover<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-number\" id=\"vfbField977\"><div class=\"vfb-form-group\"><label for=\"vfb-field-977\" class=\"vfb-control-label\">Credit Card Number: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-977\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"number\" name=\"vfb-field-977\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField978\"><div class=\"vfb-form-group\"><label for=\"vfb-field-978\" class=\"vfb-control-label\">Full Name on Credit Card: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-978\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-978\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField979\"><div class=\"vfb-form-group\"><label for=\"vfb-field-979\" class=\"vfb-control-label\">Credit Card Expiration Date <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-979\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-979\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-captcha\" id=\"vfbField980\"><div class=\"vfb-form-group\"><label for=\"vfb-field-980\" class=\"vfb-control-label\">Captcha <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"g-recaptcha\" data-sitekey=\"6LdWgN0UAAAAAM_hb1SqmzT2DP4J1X289K2epOVA\"><\/div><input type=\"hidden\" name=\"_vfb_recaptcha_enabled\" value=\"1\" id=\"\"><div class=\"vfb-has-error\" id=\"vfb-recaptcha-error\"><span class=\"vfb-help-block\">reCAPTCHA is required.<\/span><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-submit\" id=\"vfbField981\"><button id=\"vfb-field-981\" class=\" btn btn-primary\" placeholder=\"\" type=\"submit\" name=\"_vfb-submit\">Submit<\/button><\/div><div class=\"vfb-clearfix\"><\/div><\/form>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":528,"menu_order":0,"comment_status":"open","ping_status":"open","template":"","meta":{"footnotes":""},"class_list":["post-1719","page","type-page","status-publish","czr-hentry"],"_links":{"self":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/1719","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/comments?post=1719"}],"version-history":[{"count":8,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/1719\/revisions"}],"predecessor-version":[{"id":14641,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/1719\/revisions\/14641"}],"up":[{"embeddable":true,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/528"}],"wp:attachment":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/media?parent=1719"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}