Dagra Software
Sample Secure Order Form

*Fields marked with asterisk are required. Your order can not be accepted without them.
Cardholder Name and Address
*Name:
*Email Address:
Address:
City:
State/Province:
Zip/Postal code:
Country:
Phone:
 
Credit Card Information
*Card Name:
*Card Number:
5500 0000 0000 0004 or 4111 1111 1111 1111 are valid test numbers
*Expiration Date:
  
Merchandise Order
Qty:  Large Green Widgit @ $199.95 =    $
Qty:  Small Yellow Gizmo @ $10.00 =    $
Add 8% Sales Tax NYS Residents only    $
Total Credit Card Amount    $
 
Type a short comment here if you wish
 
  

 
Once you have completed the form and submitted it the system will verify required fields.
Then your order will be displayed for your own verification and correction if needed.
Upon final submission a copy of your completed order will be emailed to you as well.