177 lines
11 KiB
PHP
177 lines
11 KiB
PHP
<div class='page-box-center'>
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<h2>Send your credit card information</h2>
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<p>
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You are now using a secure connection through which your credit card
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information will be sent. Just to be sure though, make sure the Address
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box at the top of your browser reads "https://" at the beginning of the
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address and not "http://". Note the 's' after "http". If there is no 's'
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after the "http" please go to the
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<a href='https://fti.powweb.com/creditcard.php' title='Secure credit card form'>secure form</a>.
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This same page will reload, but it will now be from a secure connection.
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</p>
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<p>
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<strong>Please note:</strong> All fields are required!
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</p>
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<form action="creditcard.php" method="post" accept-charset="utf-8" id='creditcard_form'>
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<fieldset>
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<legend>Credit Card Information</legend>
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<p class='field'>
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Type of Credit Card
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<select name="card_type" id="card_type">
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<option selected="selected" value="Visa">Visa</option>
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<option value="MasterCard">MasterCard</option>
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<option value="Discover">Discover</option>
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<option value="American_Express">American Express</option>
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<option value="Diners_Club">Diner's Club</option>
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<option value="JCB">JCB</option>
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<option value="TP">TP</option>
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</select>
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</p>
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<p class='field'>
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Cardholder's Name
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<input type="text" name="card_name" id="card_name" />
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<span class="field_details">Your name as it appears on the card.</span>
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</p>
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<p class='field'>
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Credit Card Number
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<input type="text" name="card_number" id="card_number" />
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</p>
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<p class='field'>
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Security Code Number
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<input type="text" size="4" name="card_cvv" id="card_cvv" />
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<span class='field_details'>Click <a href="javascript:void(0)" id='cvv_help'>here</a> for help with the CVV number.</span>
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</p>
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<p class='date'>
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Expiration Date (mm/yyyy)
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<span class='date_fields'>
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<select name="card_expiration_month" id="card_expiration_month">
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<option>01</option>
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<option>02</option>
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<option>03</option>
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<option>04</option>
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<option>05</option>
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<option>06</option>
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<option>07</option>
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<option>08</option>
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<option>09</option>
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<option>10</option>
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<option>11</option>
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<option>12</option>
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</select>
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<select name="card_expiration_year" id="card_expiration_year">
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<?php foreach(range(date('Y'),date('Y')+20) as $year): ?>
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<option><?php echo $year ?></option>
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<?php endforeach; ?>
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</select>
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</span>
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</p>
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</fieldset>
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<fieldset>
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<legend>Billing Address</legend>
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<p class='field'>
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Full Name
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<input type="text" size="20" name="billing_full_name" id="billing_full_name" />
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</p>
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<p class='field'>
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Address
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<input type="text" size="25" name="billing_address_line1" id="billing_address_line1" />
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</p>
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<p class='field'>
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<input type="text" size="25" name="billing_address_line2" id="billing_address_line2" />
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</p>
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<p class='field'>
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City
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<input type="text" size="25" name="billing_city" id="billing_city" />
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</p>
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<p class='field'>
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State/Province/Region
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<input type="text" size="25" name="billing_state" id="billing_state" />
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</p>
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<p class='field'>
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ZIP/Postal Code
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<input type="text" size="10" name="billing_postal_code" id="billing_postal_code" />
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</p>
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<p class='field'>
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Country
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<select name="billing_country" id="billing_country">
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<option selected="selected"> United States</option><option>Afghanistan</option><option>Albania</option>
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<option>Algeria</option><option>American Samoa</option><option>Andorra</option><option>Anguilla</option>
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<option>Antarctica</option><option>Antigua And Barbuda</option><option>Argentina</option>
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<option>Armenia</option><option>Aruba</option><option>Australia</option>
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<option>Austria</option><option>Azerbaijan</option><option>Bahamas</option>
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<option>Bahrain</option><option>Bangladesh</option><option>Barbados</option>
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<option>Belarus</option><option>Belgium</option><option>Belize</option>
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<option>Benin</option><option>Bermuda</option><option>Bhutan</option>
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<option>Bolivia</option><option>Bosnia and Herzegovina</option><option>Botswana</option>
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<option>Bouvet Island</option><option>Brazil</option><option>British Indian Ocean Territory</option>
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<option>Brunei Darussalam</option><option>Bulgaria</option><option>Burkina Faso</option>
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<option>Burundi</option><option>Cambodia</option><option>Cameroon</option><option>Canada</option>
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<option>Cape Verde</option><option>Cayman Islands</option><option>Central African Republic</option>
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<option>Chad</option><option>Chile</option><option>China</option><option>Christmas Island</option>
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<option>Cocos (Keeling) Islands</option><option>Colombia</option><option>Comoros</option>
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<option>Congo</option><option>Congo, the Democratic Republic of the</option><option>Cook Islands</option>
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<option>Costa Rica</option><option>Cote d'Ivoire</option><option>Croatia</option><option>Cyprus</option>
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<option>Czech Republic</option><option>Denmark</option><option>Djibouti</option><option>Dominica</option>
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<option>Dominican Republic</option><option>East Timor</option><option>Ecuador</option><option>Egypt</option>
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<option>El Salvador</option><option>England</option><option>Equatorial Guinea</option><option>Eritrea</option>
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<option>Espana</option><option>Estonia</option><option>Ethiopia</option><option>Falkland Islands</option>
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<option>Faroe Islands</option><option>Fiji</option><option>Finland</option><option>France</option>
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<option>French Guiana</option><option>French Polynesia</option><option>French Southern Territories</option>
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<option>Gabon</option><option>Gambia</option><option>Georgia</option><option>Germany</option>
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<option>Ghana</option><option>Gibraltar</option><option>Great Britain</option><option>Greece</option>
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<option>Greenland</option><option>Grenada</option><option>Guadeloupe</option><option>Guam</option>
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<option>Guatemala</option><option>Guinea</option><option>Guinea-Bissau</option><option>Guyana</option>
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<option>Haiti</option><option>Heard and Mc Donald Islands</option><option>Honduras</option>
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<option>Hong Kong</option><option>Hungary</option><option>Iceland</option><option>India</option>
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<option>Indonesia</option><option>Ireland</option><option>Israel</option><option>Italy</option>
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<option>Jamaica</option><option>Japan</option><option>Jordan</option><option>Kazakhstan</option>
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<option>Kenya</option><option>Kiribati</option><option>Korea, Republic of</option><option>Korea (South)</option>
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<option>Kuwait</option><option>Kyrgyzstan</option><option>Lao People's Democratic Republic</option>
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<option>Latvia</option><option>Lebanon</option><option>Lesotho</option><option>Liberia</option>
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<option>Liechtenstein</option><option>Lithuania</option><option>Luxembourg</option><option>Macau</option>
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<option>Macedonia</option><option>Madagascar</option><option>Malawi</option><option>Malaysia</option>
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<option>Maldives</option><option>Mali</option><option>Malta</option><option>Marshall Islands</option>
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<option>Martinique</option><option>Mauritania</option><option>Mauritius</option><option>Mayotte</option>
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<option>Mexico</option><option>Micronesia, Federated States of</option><option>Moldova, Republic of</option>
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<option>Monaco</option><option>Mongolia</option><option>Montserrat</option><option>Morocco</option>
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<option>Mozambique</option><option>Namibia</option><option>Nauru</option><option>Nepal</option>
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<option>Netherlands</option><option>Netherlands Antilles</option><option>New Caledonia</option>
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<option>New Zealand</option><option>Nicaragua</option><option>Niger</option><option>Nigeria</option>
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<option>Niue</option><option>Norfolk Island</option><option>Northern Ireland</option>
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<option>Northern Mariana Islands</option><option>Norway</option><option>Oman</option>
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<option>Pakistan</option><option>Palau</option><option>Panama</option><option>Papua New Guinea</option>
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<option>Paraguay</option><option>Peru</option><option>Philippines</option><option>Pitcairn</option>
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<option>Poland</option><option>Portugal</option><option>Puerto Rico</option><option>Qatar</option>
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<option>Reunion</option><option>Romania</option><option>Russia</option><option>Russian Federation</option>
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<option>Rwanda</option><option>Saint Kitts and Nevis</option><option>Saint Lucia</option>
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<option>Saint Vincent and the Grenadines</option><option>Samoa (Independent)</option>
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<option>San Marino</option><option>Sao Tome and Principe</option><option>Saudi Arabia</option>
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<option>Scotland</option><option>Senegal</option><option>Seychelles</option><option>Sierra Leone</option>
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<option>Singapore</option><option>Slovakia</option><option>Slovenia</option><option>Solomon Islands</option>
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<option>Somalia</option><option>South Africa</option><option>South Georgia and the South Sandwich Islands</option>
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<option>South Korea</option><option>Spain</option><option>Sri Lanka</option><option>St. Helena</option>
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<option>St. Pierre and Miquelon</option><option>Suriname</option><option>Svalbard and Jan Mayen Islands</option>
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<option>Swaziland</option><option>Sweden</option><option>Switzerland</option><option>Taiwan</option>
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<option>Tajikistan</option><option>Tanzania</option><option>Thailand</option><option>Togo</option>
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<option>Tokelau</option><option>Tonga</option><option>Trinidad</option><option>Trinidad and Tobago</option>
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<option>Tunisia</option><option>Turkey</option><option>Turkmenistan</option><option>Turks and Caicos Islands</option>
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<option>Tuvalu</option><option>Uganda</option><option>Ukraine</option><option>United Arab Emirates</option>
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<option>United Kingdom</option><option>United States</option><option>United States Minor Outlying Islands</option>
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<option>Uruguay</option><option>USA</option><option>Uzbekistan</option><option>Vanuatu</option>
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<option>Vatican City State (Holy See)</option><option>Venezuela</option><option>Viet Nam</option>
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<option>Virgin Islands (British)</option><option>Virgin Islands (U.S.)</option><option>Wales</option>
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<option>Wallis and Futuna Islands</option><option>Western Sahara</option><option>Yemen</option>
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<option>Yugoslavia</option><option>Zambia</option><option>Zimbabwe</option>
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</select>
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</p>
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<p class='field'>
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E-mail Address
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<input type="text" size="25" name="billing_email" id="billing_email" />
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</p>
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</fieldset>
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<p>
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<input type="submit" value="Submit Information">
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</p>
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</form>
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</div>
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