Creation of PCI Compliant Subscription form for our Website and Wishbox Forms

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    Asked on December 01, 2011 at 01:44 PM

    12/1/2011 12:38:31 PM CWH Dubai Technologies, International1565 West Main Street, Suite 208-160Lewisville, Texas 75067-3397Office: (877) 845-3598 / (940) 725-0547 / Mobile: (469) 243-8513│Facsimile: (866) 350-2667│Email:  tjhsr734@WEBCWH.CO.UK® 2001-2012™ © CWH Dubai Technologies, : This e-mail address is being protected from spambots. You need JavaScript enabled to view it


    2012 EHR / ERM List for E-Health-Care Records Management, Commercial Records Management Globally, and all National Pharmacies / E-Records Management


        Minimum (2) Two year subscription minimum                Link Directly to This Package Starting at: $175K / Month  X-12= (9 Racks)  24/7/356 Technical Support Globally  //Microsoft Exchange Email Account Hosted Up to 1000 Accounts  adding Blocks of 100-Unlimited, and Billed Separately Under Corporate Domains / 1st. and Last Month Paid Up-Front, and Security Deposit Equaling $375/Month   Five Year Subscriptions        Link Directly to This Package  Starting at: $135.50-K / Month X- 60=Months Per Rack(s)  24/7/365 Dedicated Network Monitoring, Microsoft Exchange Email Accounts, Unified Communication Manager Servicing, Updates, Security; Inclusive of All Services in Two Agreements with Signed Contractual Agreement for Five years Services / 1st. and Last Month Paid Up-Front, as Security  Deposit           (email/online/Telephony & UCM)        Link Directly to This Package  Starting at: $185.99 K Per Month (via email/online, Telephony Systems, Unified Communications Manager) Inclusive of All Services with Signed Contractual Agreement for Five years Services Listed in Five year Plans For multiple email/online users please contact subscriptions for price upon request  Quarterly Newsletter (CWH)        1 month only (email/online) Free for Those Clients Who Sign a Two to Five Service Agreement all Others Starting at: $36.50 per month   CWH Media Extra  (Email / Online / Website(s) Hosting)        Link Directly to THis Package Starting at: $1,225 Per Month (with CWH subscription services offers 24/7/365 Technical Support, Cloud Computing 23rd. Century Designs in Advance Technological) Network Design Team, Deployment, Security Engineers,$250 per annum (weekly, annual subscription(s) to Tele-Presence / Health-Presence Units MPLS.For multiple email/online users please contact subscriptions for price upon request Al Carte Menu:  (CWH) (email)        Link Directly to This Package Starting at: $250k per annum (via EHR /  E-Billings Services Added for Direct Billings Incorporated for Direct billing Insurance Carriers for Each Medical Group(s) Hospitals, Trauma Centers, Small Medical Group(s), Microsoft Exchange Email, Single and Multiply  recipient(s)  ERM Commercial / Private ClientsFor multiple email users please contact subscriptions for pricing upon request    


    o     OVERSEAS PRICES AVAILABLE ON upon Requests

    ·         All prices Subject to State and Federal Taxes (where applicable)

    ·         Prices are Subject to Change without Notice When No Contract is Effective

    ·         All prices quoted are GST inclusive (overseas customers exempt from GST)

    ·         Subscriptions cannot be cancelled Mid-Term NS Only With Written Notification

    ·         Claims must be made within 3 Months from date of Issue

    ·         Full Payment(s)  of  Security Deposits and all Deposits Required Prior to Subscription Commencement; Clients Shall Provide CWH Dubai All Written Requirements of their Particular needs and purposes of uses in their facilities, at time of Signing Subscription Contracts Agreements Order and Global Network(s) Deployments in Global Environments




       YES!    Please commence my subscription to the product/s checked above.


    Type or Print in Legible Script:


    Enclosed is my Cheque/Bank Draft Payable to CWH Dubai Technologies International, LLC. USA/UAE/UK/CN for $_________________


    OR Please debit my:  r Bankcard   r Diners Club   r American Express   r MasterCard   r Visa Card


    Card #  ê__ ê__ê__ê__êê__ê__ê__ê__çê__ê__ê__ê__çê__ê__ê__ê__ç             Authorize Signature:                                                                               


    Expiry Date: ___________________/____________________


    Three Digits Security Code on Back of Credit Card: --------------               Name on Card:                                                                                       


    (Mr. / Mrs / Ms) First Name:  _____________________________             Surname:                                                                                               


    Job Title: __________________________________________                  Company:                                                                                              




    _______________________________Postcode:                                                                                                           Email___________________________________________________________


    Phone: ____________________________________________ Fax: __________                                                                                                     


    Main business activity: ______________________________________________________________________________________________________




    r Please check this box if you do not want to receive other Promotional Material(s).



    “CWH Dubai Technologies Int’l., Suppliers, Vendors, Et al, ; shall not any way Held Liable or make no expressed warranties; Regarding the Acts or Lack or Actions by sub-contractors, Agents, Associates, Business Partners,  or Successors, Responsible for Errors/Typo’s, and Omissions in  any Written Format on the CWH Dubai Technologies International, LLC USA/UAE/UK/CN Website(s) Print Materials, Publications, on CWH Dubai Tech., Subscription Page(s) Submitted by Clients / Verbal/Statements are not Valid,  only; Written Agreements Signed by All Parties, and Not Part of the Actual Subscription Form/Applications, Work Stoppages, by Suppliers Vendors, Equipment(s) Delivery Dates As Promised, Defective Equipment, Acts of Nature; but CWH Dubai Tech.;  Shall make every Attempt to Resolve any and all Issues Immediately for Our clients by our and Business Associates, Affiliates, or Business Partners, Successors, Agents, Representatives Related to Clients Service Agreements Signed by all Parties or Problems, Defects, Maintenance issues, Technical Issues that may arise during and “Valid and Signed by all Parties Service Agreement(s)” in Place which may Occur” Separate itemized Documents shall Line items of which the clients has purchased via electronic transmissions Hard Copy via U. S. Postal Services to last known Address on File of clients formally signed and credit card processing completed, services shall be ordered immediately and implemented as soon as possible applications for services.


    All Unresolved Disputes; Shall Resolved by Binding Arbitration in the State of Texas of Legal Jurisdictions (See Our Privacy Policy on our Website: ) © ® 2001-2012 All Rights Reserved and protected under US and International Laws



    Please Utilize our Online Subscriptions Credit Card Processing Fax or Mail Entire Page. Thank you.


    (EHR / ERM): E-Health-Care Records Management, E-Acute Emergency Health-Care, and E-Health-Care.


    CWH Dubai Technologies International, LLC. USA/UAE/UK/CN: Accessed Over a Globally Layered Security, 24/7/365 Including Cloud Computing, Monitoring, Hosted by Verizon Business, and Supplies, In conjunction with CWH Dubai And CISCO Systems; in their  Specially Secured Hosting Facilities: HIPPA Complaint, PCI Complaint, Islamic Laws, Culture, Religious Laws, and European Compliance Policies: E-Health-Care Records Management, E-Acute Emergency Health-Care, and E-Health-Care.


           E.H.R. Global Networks 23rd Century Newly Designed National Health-Care Re-Depositories Health-Care Records Management, and E-Acute Health-Care; Clustering


            i.           Small to Large Medical Groups

          ii.           Medical Centers / Medical Cities

         iii.           Local Hospitals

         iv.           College / Universities

          v.           Grade, though High Schools

         vi.           Hotels / Resorts / Health-Spa’s

        vii.           Airports / Government Facilities (Separate Servers and Firewalls), Shopping Malls / Casinos / Airports / Shopping Malls / Casinos / Plans for On-Board International Commercial Aircrafts, Limit Liabilities of  Commercial Airlines, as Pro-Active in Passenger Safety; While On-Board Commercial International Carriers via Health-Presence Units in Direct Contact with Nearest Land Based Trauma Center, and Redundancies Built into Continuances Network(S) Up-Time 24/7/365

       viii.           Patients “Only Complete One Set of Forms for All Medical Requirements: Listing Any and All Medical Clinicians, medicines Taken, including Over the Counter, health Care providers, treatments, Surgeries, Procedures, Implants, Stents, Prosthetics; and Stored on Separate Servers for Individualized Clients Needs and Requirements

           E.R.M. Commercial Clients Global Access; Clustering

           Church’s Record Management


         ix.           Commercial Clients and Private Clients Needs

          x.           Disaster Recovery Global Networks; Clustering


    Please check this box if you do not want to receive other promotional material.


    ( Phone Subscriptions: (+1) (877) 845-35898 / (940) 725-0547 / Ê Fax: (+1) 866- 350-2667


     Email: / / /


    * Mail / Facsimile, Completed Subscriptions to Below or Facsimile above Fax No:

    ® ™2001-2012 CWH Dubai Technologies International, LLC. USA/UAE/UK/CN

    1565 West Main Street, Ste.-208-160; Lewisville, Texas 75067-3397 / U.S.A.


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  • Profile Image
    Answered on December 01, 2011 at 02:37 PM


    I'm afraid you have included unnecessary data in your post but to get back on your question about PCI Compliance, we don't have any certificate but your form's data, by default, is not viewable by anybody other than you.

    If you are worried about us storing any credit card info, we don't keep any of those information as the API integration makes sure that you are negotiating directly with the Payment Gateways.

    Please don't hesitate to reply if you need some clarifications.

    Thank you for using JotForm. 

  • Profile Image
    Answered on December 01, 2011 at 02:57 PM
    Network Solutions Referral Given for Use of JotForm:
    Can You Complete our Form Immediately as we paid for Monthly Services,

    Moreover, I have a major medical issues over the last several months and our Website Designers are closing our Modification Early next Week!

    So we need our Subscription Form Prepared and Ready to send over to them as they recommended JotForm as the Choice for Our Subscription Form.

    Must have SSL Label attached as Our Website is already PCI Complaint and HIPPA Complaint with 256 BIT Encryption Installed on Site.

    Attached Subscription Model / Format: We already attempted to upload Several times over your web portal

    I Personally Thank You In Advance for Your Every Consideration and Cooperation in these Matters.

    T. (Ted) James Henderson, Senior
    01, Ddecember 2011
    “Attached Files, are Patent, Trademark, Copyright Under, International and U.S. Laws; Shall Not Be Disclosed, Disseminated in any Format, Copied, Transmitted, Facsimile, Duplicated, Without Expressed Written Permission of the Board of Directors of CWH Dubai Technologies, International, Limited, CA., USA/UAE/UK/CN; Failure, Shall Result in Sever Legal Penalties, Including Fines, Criminal, and Civil Prosecutions or Both”
    This Electronic transmission (and / or the Attachment(s) and Documents Accompanying it) May Contain Confidential Information Belonging to the Sender(s) that Is Protected by the Electronic Communications Privacy Act, 18 U.S.C. Sections 2510 and 2521 and may be legally privileged. This Message (and any Attachment(s) Associated Files are Intended Only for the Use of the Individual(s), Agents, Successors, or Entities to Which it is Addressed and May Contain Information that is Confidential Subject to Copy Right or Constitutes a Trade Secret; If you are not the Intended Recipient or their Agent; You are Hereby Notified that any Dissemination, Copying, forwarding or Distributing of these files and an Attachments Associated with the Files with this Message, is Strictly Prohibited. Any of these Actions will Result in Civil and Criminal Prosecutions under Federal and Local Laws. If you received this Fax, Email Transmission in Error, Please Notify Cooper, Wilson Henderson, Inc, Layered Technologies, and CISCO Systems & CWH Dubai Development LLC. U.S.A. / U.A.E. & CWH Dubai Technologies, International, Limited, CA. U.S.A. / U.A.E. Immediately and Delete All Files and Associate Files from Your Machine and Databases and Contact Us Immediately via Telephone Numbers Listed.

    T. (Ted) James Henderson, Senior:
    Email: tjhsr734@WEBCWH.CO.UK /
    President / CEO
    Office: (877) 845-3589 / (940) 725-0410 / Cell: (469) 243-8513 / CWH Dubai Skype NO: (469) 575-5250
    Description: Description: CWH-LO-FF (3) jpg 20 May 2010
    Curtis Jackson, Jr: Email:
    Vice Chairman
    Office: (877) 845-3589 / (940) 725-0410 / (940) 725-0410 / Cell: (919) 265-7283
    Description: Description: CWH-LO-FF (3) jpg 20 May 2010

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    Answered on December 01, 2011 at 07:38 PM

    Hello James,

    JotForm provides form building tools for its users. Whilst we are eager to help our users as much as possible, we dont actually build the forms for them, subscriber or non-subscriber. 

    We will hold peoples hand as much as they want, but you or someone in your organisation is going to have to sit down and at least start to build your form to whatever requirements you need using JotForms tools.

    This form building task is something that your website designers should probably be doing.


    Thanks for your understanding.