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<TR>
<TD ALIGN="right">Card number</TD>
<TD>
<TABLE>
<TR>
<TD>
<INPUT TYPE="text" NAME="payinfo" SIZE=20 MAXLENGTH=19 VALUE="<%=$payinfo%>"> </TD>
<TD>Exp.</TD>
<TD>
<SELECT NAME="month">
<%= for ( ( map "0$_", 1 .. 9 ), 10 .. 12 ) {
$OUT .= '<OPTION'. ($_ == $month ? ' SELECTED' : ''). ">$_\n";
} %>
</SELECT>
</TD>
<TD> / </TD>
<TD>
<SELECT NAME="year">
<%= my @a = localtime; for ( $a[5]+1900 .. $a[5]+1915 ) {
$OUT .= '<OPTION'. ($_ == $year ? ' SELECTED' : ''). ">$_\n";
} %>
</SELECT>
</TD>
</TR>
</TABLE>
</TD>
</TR>
<%=
if ( $withcvv ) {
$OUT .= qq!<TR>!;
$OUT .= qq!<TD ALIGN="right">CVV2 (<A HREF="javascript:myopen('cvv2.html','cvv2','toolbar=no,location=no,directories=no,status=no,menubar=no,scrollbars=no,resizable=yes,copyhistory=no,width=480,height=288')">help</A>)</TD>!;
$OUT .= qq!<TD><INPUT TYPE="text" NAME="paycvv" VALUE="" SIZE=4 MAXLENGTH=4></TD>!;
$OUT .= qq!</TR>!;
}
'';
%>
<TR>
<TD ALIGN="right">Exact name on card</TD>
<TD><INPUT TYPE="text" SIZE=32 MAXLENGTH=80 NAME="payname" VALUE="<%=$payname%>"></TD>
</TR><TR>
<TD ALIGN="right">Card billing address</TD>
<TD>
<INPUT TYPE="text" SIZE=40 MAXLENGTH=80 NAME="address1" VALUE="<%=$address1%>">
</TD>
</TR><TR>
<TD ALIGN="right">Address line 2</TD>
<TD>
<INPUT TYPE="text" SIZE=40 MAXLENGTH=80 NAME="address2" VALUE="<%=$address2%>">
</TD>
</TR><TR>
<TD ALIGN="right">City</TD>
<TD>
<TABLE>
<TR>
<TD>
<INPUT TYPE="text" NAME="city" SIZE="12" MAXLENGTH=80 VALUE="<%=$city%>">
</TD>
<TD>State</TD>
<TD>
<SELECT NAME="state">
<%= for ( @states ) {
$OUT .= '<OPTION'. ($_ eq $state ? ' SELECTED' : '' ). ">$_\n";
} %>
</SELECT>
</TD>
<TD>Zip</TD>
<TD>
<INPUT TYPE="text" NAME="zip" SIZE=11 MAXLENGTH=10 VALUE="<%=$zip%>">
</TD>
</TR>
</TABLE>
</TD>
</TR>
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