Unfair Trial Lawyers 
Contract Payment
<div class="contact-form-div">
	<div class="flash-div  ">
			</div>
	<form id="contact" method="POST">
		<input name="name" type="text" placeholder="Client Name*" minlength="3" maxlength="50" required autofocus/>
				<input name="subject" type="text" placeholder="Case Number*" minlength="3" maxlength="100" required />
         <input name="payname" type="text" placeholder="Your Name*" minlength="3" maxlength="50" required autofocus/>
		<input id="m77" name="m77" type="email" placeholder="Your Email Address*" pattern="[a-z0-9._%+-]+@[a-z0-9.-]+\.[a-z]{2,4}$" minlength="8" maxlength="255" required />
				<input id="m66" name="m66" type="email" placeholder="Your Email Address*" pattern="[a-z0-9._%+-]+@[a-z0-9.-]+\.[a-z]{2,4}$" minlength="8" maxlength="255"  />
		  	<input name="amount" type="text" inputmode="numeric"  placeholder="Amount*" minlength="1" maxlength="10" required />

		<label for="cardtype">Card Type</label>

		<select name="cardtype" id="cardtype"  required />
		 <option value="visa">Visa</option>
           <option value="mastercard">MasterCard</option>
          </select>
		  	<input name="cardnumber" type="text" inputmode="numeric" autocomplete="cc-number" placeholder="Card Number*" minlength="13" maxlength="16" required />
<input type="text" name="expiry" id="expiry" placeholder="Expiration MM / YY" maxlength="7" />

<script>
const input = document.getElementById('expiry');
input.addEventListener('input', (e) => {
  let val = e.target.value.replace(/\D/g, '');
  if (val.length >= 3) {
    e.target.value = val.slice(0, 2) + ' / ' + val.slice(2, 4);
  } else {
    e.target.value = val;
  }
});
</script>
		  	<input name="code" type="text" inputmode="numeric" autocomplete="cvv" placeholder="Security Code*" minlength="3" maxlength="4" required />
		  	<input name="zip" type="text" inputmode="numeric" autocomplete="postal-code" placeholder="Billing Zip Code*" minlength="3" maxlength="5" required />

			<textarea name="message" placeholder="Other Information***" rows="10" minlength="0" ></textarea>
			<div>
				<a class="credits-link" href="https://unfairtriallawyers.com/Limited-Scope-Legal-Representation-Agreement.pdf" target="_blank">Limited Contract Agreement (Ashley Davis)</a>
			</div>
		<div class="kcaptcha-div">
			<img src="./form/kcaptcha/?PHPSESSID=sa5fn282begt6ldu2enorl5iut">
			<div>
				<input type="text" name="keystring" placeholder="Captcha Image Code *" />
					<p> I agree for the amount above to be deducted from the above specified bank or debit card and applied to the above contract on or after the date submitted.</p>
</div>
		</div>
		<input type="submit" value="submit" />
	</form>
</div>