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">