| Name on card: <input autofocus="" type="text" name="name" id="credit_card_name"><br> |
| Credit card number: <input type="text" name="CCNo" id="credit_card_number"><br> |
| Expiry Date: <select name="CCExpiresMonth"> |
| <option value="01">01</option> |
| <option value="02">02</option> |
| <option value="03">03</option> |
| <option value="04">04</option> |
| <option value="05">05</option> |
| <option value="06">06</option> |
| <option value="07">07</option> |
| <option value="08">08</option> |
| <option value="09">09</option> |
| <option value="10">10</option> |
| <option value="11">11</option> |
| <option value="12">12</option> |
| </select> |
| / |
| <select name="CCExpiresYear"> |
| <option value="2010">2010</option> |
| <option value="2011">2011</option> |
| <option value="2012">2012</option> |
| <option value="2013">2013</option> |
| <option value="2014">2014</option> |
| <option value="2015">2015</option> |
| <option value="2016">2016</option> |
| <option value="2017">2017</option> |
| <option value="2018">2018</option> |
| <option value="2019">2019</option> |
| <option value="2020">2020</option> |
| <option value="2021">2021</option> |
| <option value="2022">2022</option> |
| <option value="2023">2023</option> |
| </select> |
| <br> |
| CVC: <input name="cvc"> |
| <br> |
| <input type="reset" value="Reset"> |
| <input type="submit" value="Submit" id="credit_card_submit"> |