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Text File  |  2002-11-14  |  2.9 KB  |  101 lines
  1. <!-- Action must be changed to suit your script and server path. Change names and values as needed -->
  2. <!-- WARNING:Form transfer involving credit card numbers must reside on a secure server. Contact your Host/ISP for more information  -->
  3. <table width="500" border="0" cellspacing="0" cellpadding="0">
  4. <form method="post" action="/phpbin/yourscript.php">
  5. <tr>
  6.     <td align="right" bgcolor="#D1D1D1"><b>Customer Information:</b></td>
  7.     <td bgcolor="#D1D1D1"> </td>
  8. </tr>
  9. <tr>
  10.     <td align="right">Your Name:</td>
  11.     <td><input type="text" name="name"></td>
  12. </tr>
  13. <tr>
  14.     <td align="right">Company:</td>
  15.     <td><input type="text" name="company"></td>
  16. </tr>
  17. <tr>
  18.     <td align="right">Email Address:</td>
  19.     <td><input type="text" name="email"></td>
  20. </tr>
  21. <tr>
  22.     <td align="right">Geographical Address:</td>
  23.     <td><input type="text" name="address"></td>
  24. </tr>
  25. <tr>
  26.     <td align="right">City/Town:</td>
  27.     <td><input type="text" name="city"></td>
  28. </tr>
  29. <tr>
  30.     <td align="right">State/Province:</td>
  31.     <td><input type="text" name="state"></td>
  32. </tr>
  33. <tr>
  34.     <td align="right">Zip/Postal:</td>
  35.     <td><input type="text" name="zip"></td>
  36. </tr>
  37. <tr>
  38.     <td align="right">Country:</td>
  39.     <td><input type="text" name="country"></td>
  40. </tr>
  41. <tr>
  42.     <td align="right">Telephone:</td>
  43.     <td><input type="text" name="telephone"></td>
  44. </tr>
  45. <tr>
  46.     <td align="right">Fax:</td>
  47.     <td><input type="text" name="fax"></td>
  48. </tr>
  49. </table>
  50. <br>
  51. <table width="500" border="0" cellspacing="0" cellpadding="0">
  52. <tr>
  53.     <td align="right" bgcolor="#D1D1D1"><b>Select Your Product:</b></td>
  54.     <td bgcolor="#D1D1D1"> </td>
  55. </tr>
  56. <tr>
  57.     <td align="right"><input type="radio" name="order" value="ys-15.00" Checked></td>
  58.     <td>Yellow Scarf - $15.00</td>
  59. </tr>
  60. <tr>
  61.     <td align="right"><input type="radio" name="order" value="gg-20.00"></td>
  62.     <td>Green Gloves - $20.00</td>
  63. </tr>
  64. <tr>
  65.     <td align="right"><input type="radio" name="order" value="rs-25.00"></td>
  66.     <td>Red Skirt - $25.00</td>
  67. </tr>
  68. <tr>
  69.     <td align="right"><input type="radio" name="order" value="bh-30.00"></td>
  70.     <td>Blue Hat - $30.00</td>
  71. </tr>
  72. </table>
  73. <br>
  74.  
  75. <table width="500" border="0" cellspacing="0" cellpadding="0">
  76. <tr>
  77.     <td align="right" bgcolor="#D1D1D1"><b>Payment Information:</b></td>
  78.     <td bgcolor="#D1D1D1"> </td>
  79. </tr>
  80. <tr>
  81.     <td align="right">Select Method:</td>
  82.     <td><input type="radio" name="card" value="visa" Checked>Visa  <input type="radio" name="card" value="mastercard">Mastercard</td>
  83. </tr>
  84. <tr>
  85.     <td align="right">Credit Card Number:</td>
  86.     <td><input type="text" name="ccname"></td>
  87. </tr>
  88. <tr>
  89.     <td align="right">Expiry Date:</td>
  90.     <td><input type="text" name="ccexpiry"></td>
  91. </tr>
  92. <tr>
  93.     <td align="right">Cardholder:</td>
  94.     <td><input type="text" name="ccholder"></td>
  95. </tr>
  96. <tr>
  97.     <td> </td>
  98.     <td><input type="submit" value="Submit"><input type="reset"></td>
  99. </tr>
  100. </form>
  101. </table>