Corporate Body ?

{{ env('APP_NAME_') }} (xxx-xxxx-xxxx) @error("birs_id") {{ $message }} @enderror

TIN @error("tin") {{ $message }} @enderror

First Name * @error("fnname") {{ $message }} @enderror

Last Name * @error("last_name") {{ $message }} @enderror

Payer's Phone * @error("phone") {{ $message }} @enderror

Payer's Email @error("email") {{ $message }} @enderror

ID type @error("id_type") {{ $message }} @enderror

ID Number @error("id_number") {{ $message }} @enderror

@can("view_all_mdas")

Select MDA

@endcan

Select Service

Select Revenue Points

Amount To Pay *

Click to set amount.

Select Payment Method *

Description (optional)