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| 1 <!-- https://www.jbox.com/checkout/payment# --> |
| 2 <form name="paymentForm" method="post" action="#" id="paymentForm"> |
| 3 <div id="errors"></div> |
| 4 <fieldset id="paymentchoose"> |
| 5 <legend>Choose a payment method</legend> |
| 6 <div> |
| 7 <select id="paymentoption" accesskeyclass="element select medium" name="pa
yment_method" onchange="changePayment()"> |
| 8 <option selected="selected"> |
| 9 Visa |
| 10 </option> |
| 11 <option> |
| 12 Mastercard |
| 13 </option> |
| 14 <option> |
| 15 American Express |
| 16 </option> |
| 17 <option> |
| 18 Discover |
| 19 </option> |
| 20 <option> |
| 21 Card on File (provide CVV2) |
| 22 </option> |
| 23 <option> |
| 24 Check / Money Order |
| 25 </option> |
| 26 <option> |
| 27 Gift Certificate / Credit |
| 28 </option> |
| 29 <option> |
| 30 Western Union (we'll send instructions) |
| 31 </option> |
| 32 <option value="PayPal"> |
| 33 PayPal |
| 34 </option> |
| 35 <option value="Google Checkout"> |
| 36 Google Checkout |
| 37 </option> |
| 38 </select> |
| 39 </div> |
| 40 </fieldset> |
| 41 <fieldset id="ccinput"> |
| 42 <legend>Credit Card Details</legend> |
| 43 <div> |
| 44 <input name="cc_number" class="element text medium" type="text" maxlength=
"255" value=""> <label for="address1"><b>Credit Card Number</b></label> |
| 45 </div> |
| 46 <div> |
| 47 <input name="cc_name" class="element text medium" type="text" maxlength="6
0" value=""> <label for="address1">Name On Card | Ex: <i>Peter Payne</i></label> |
| 48 </div> |
| 49 <div class="left"> |
| 50 <span><input name="cc_exp" class="element text small" type="text" maxlengt
h="255" value=""> <label for="cc_exp">Expiration date<br> |
| 51 (MM/YY)</label></span> |
| 52 </div> |
| 53 <div> |
| 54 <span><input name="cc_cvv2" class="element text small" type="text" maxleng
th="255" value=""> <label for="cc_cvv2">CVV2 / Security Code:</label></span> |
| 55 </div> |
| 56 </fieldset> |
| 57 <fieldset> |
| 58 <legend>If an item is not available:</legend> <select name="field_17"> |
| 59 <option value="Select an option..."> |
| 60 Select an option... |
| 61 </option> |
| 62 <option value="Cancel the item"> |
| 63 Cancel the item |
| 64 </option> |
| 65 <option value="Wait for all items to be available"> |
| 66 Wait for all items to be available |
| 67 </option> |
| 68 <option value="Split and send separately (additional fees apply)"> |
| 69 Split and send separately (additional fees apply) |
| 70 </option> |
| 71 </select> |
| 72 </fieldset> |
| 73 <fieldset> |
| 74 <legend>Please confirm your age</legend> <input name="age" class="element te
xt small" type="text" maxlength="255" value=""> |
| 75 </fieldset> |
| 76 <fieldset> |
| 77 <legend>Comment or Special Instructions (if any)</legend> |
| 78 <textarea id="element_6" name="comments" class="element textarea small"></te
xtarea> |
| 79 </fieldset><input type="hidden" name="paymentForm" value="259215"> <input id="
placeorder" class="button_text" type="submit" name="submit" value="Place Order"> |
| 80 </form> |
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