UPMC BU > CloudPages > API Internal Testing Forms > Early Payment Discount Form - TEST FORM


      <h2>Early Payment Discount Form - Test Form</h2>
      <form action="https://pages.upmc.com/early-payment-discount-api-internal-testing-form" method="post">

         <label for="submission_date">Submission Date</label>
            <input type="date" id="submission_date" name="submission_date"
               value="mm-dd-yyyy"
               min="2021-01-01" max="2024-12-31"><br>

         <label>Supplier Legal Name</label>
         <input type="text" name="supplier_legal_name"><br>

         <label>Federal Tax ID Number</label>
         <input type="text" name="federal_tax_id_number"><br>

          <label>Discount Term</label>
            <select name="discount_term" id="discount_term">
               <option value="" selected="selected">Select One</option>
               <option value="2% Disc in 10 days, NET 30">2% Disc in 10 days, NET 30</option>
               <option value="1.5% Disc in 15 days, NET 30">1.5% Disc in 15 days, NET 30</option>
               <option value="1% Disc in 20 days, NET 30">1% Disc in 20 days, NET 30</option>
               <option value="0.5% Disc in 25 days, NET 30">0.5% Disc in 25 days, NET 30</option>
            </select><br><br>

         <p>Supplier Representative Approving Term Change:</p>

         <label>Email</label>
         <input type="text" name="email_address"><br>
         <label>Full Name</label>
         <input type="text" name="full_name"><br>
         <label>Title</label>
         <input type="text" name="title"><br>
         <label>Phone Number</label>
         <input type="text" name="phone_number"><br>
         <label>Category</label>
         <input type="text" name="category"><br>
         <label>Subcategory</label>
         <input type="text" name="subcategory"><br><br>
         <input name="submitted" type="hidden" value="true" />
         <input type="submit" value="Submit">
      </form>