<FORM name=recieptForm action=/portal/rm/esurcharge?_DARGS=/portal/rmgroup/apps/templates/html/surcharge/receipt.jsp method=post><INPUT type=hidden value=ISO-8859-1 name=_dyncharset>
Please print and retain your receipt for future reference.
Below are the details of your receipt
Your details
Your reference number:
3-1000000521898
</FORM>