Credit Card Type:

<input name="card_cardType" type="radio" value="001"> Visa

<input name="card_cardType" type="radio" value="002"> MC

<input name="card_cardType" type="radio" value="003"> AMEX

<input name="card_cardType" type="radio" value="004"> Discover<br /><br />

Card Number: <input name="card_accountNumber" type="text" size="35"><br /><br />

Exp. Month: <select name="card_expirationMonth">

<?

         for ($i = 1; $i < 13; $i++)

            {

                        echo "<option value=\"$i\">$i\n";

            }

?>

</select><br /><br />

 Exp. Year: <select name="card_expirationYear">

<?

            $this_year = date('Y');

            for ($i = 0; $i < 9; $i++)

            {

                        $theyear = $this_year + $i;

                        echo "<option value=\"$theyear\">$theyear\n";

            }

?>

</select><br /><br />

Billing First Name:  <input type="text" name="billTo_firstName"><br /><br />

Billing Last Name:  <input type="text" name="billTo_lastName"><br /><br />

Billing Email:  <input type="text" name="billTo_email"><br /><br />

Billing Street: <input type="text" name="billTo_street1"><br /><br />

Billing City:  <input type="text" name="billTo_city"><br /><br />

Billing State:  <input type="text" name="billTo_state"><br /><br />

Billing Zip Code: <input type="text" name="billTo_postalCode"><br /><br />

Billing Country: <input type="text" name="billTo_country">