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Text File  |  2001-02-15  |  529 b   |  25 lines
  1. <TR>
  2. <TD>Name on Card:</TD>
  3. <TD><input type="text" name="cardname" size=30></TD>
  4. </TR>
  5. <TR>
  6. <TD>Credit Card Type:</TD>
  7. <TD>
  8. <SELECT NAME="Options" SIZE="1">
  9. <OPTION SELECTED>Choose One
  10. <OPTION>Visa
  11. <OPTION>Master Card
  12. <OPTION>Discover
  13. <OPTION>American Express
  14. <OPTION>Other
  15. </SELECT>
  16. </TD>
  17. </TR>
  18. <TR>
  19. <TD>Credit Card Number:</TD>
  20. <TD><input type="text" name="cardnum" size=20 maxlength=16></TD>
  21. </TR>
  22. <TR>
  23. <TD>Expiration Date:</TD>
  24. <TD><input type="text" name="expdate" size=6 value="  /  /  "></TD>
  25. </TR>