<TR>
<TD colspan="2" align=center><FONT FACE="arial,helvetica,san-serif"><B>Please enter your credit card information:</B></FONT></TD>
</TR>

<!-------------- credit card data ---------------------->

<TR>
<TD><IMG SRC="/images/general/dot.gif" WIDTH=200 HEIGHT=1></TD>
<TD><IMG SRC="/images/general/dot.gif" WIDTH=250 HEIGHT=1></TD>
</TR>

<!------------ card type ---------------------->

<TR>
<TD ALIGN=RIGHT><FONT FACE="arial,helvetica,san-serif" SIZE=-1>Card type:</FONT><BR>
<FONT FACE="arial,helvetica,san-serif" SIZE=-2 COLOR="#FF0000">__CCNAME_err__</FONT></TD>
<TD>
<input type="hidden" name="CCNAME_pre" value="__CCNAME_inp__">
<SELECT NAME="CCNAME_inp">
__CCNAME_SELECT__
</SELECT>
</TD></TR>

<!------------ card number ------------------->

<TR>
<TD ALIGN=RIGHT><FONT FACE="arial,helvetica,san-serif" SIZE=-1>Credit Card number:</FONT><BR>
<FONT FACE="arial,helvetica,san-serif" SIZE=-2 COLOR="#FF0000">__CCID_err__</FONT></TD>
<TD><INPUT TYPE="text" NAME="CCID_inp" VALUE="__CCID_inp__" SIZE=16></TD>
</TR>

<!------------ card expiration month ---------->

<TR>
<TD ALIGN=RIGHT><FONT SIZE=-1>Expiration month:</FONT><BR>
<FONT FACE="arial,helvetica,san-serif" SIZE=-2 COLOR="#FF0000">__CCEXPMO_err__</FONT></TD>
<TD>
<input type="hidden" name="CCEXPMO_pre" value="__CCEXPMO_inp__">
<SELECT NAME="CCEXPMO_inp">
__CCEXPMO_SELECT__
</SELECT>
</TD></TR>

<!------------ card expiration year --------->

<TR>
<TD ALIGN=RIGHT><FONT SIZE=-1>Expiration year:</FONT><BR>
<FONT FACE="arial,helvetica,san-serif" SIZE=-2 COLOR="#FF0000">__CCEXPYR_err__</FONT></TD>
<TD>
<input type="hidden" name="CCEXPYR_pre" value="__CCEXPYR_inp__">
<SELECT NAME="CCEXPYR_inp">
__CCEXPYR_SELECT__
</SELECT>
</TD></TR>

<!------------ customer service phone ------->

<TR>
<TD ALIGN=RIGHT><FONT FACE="arial,helvetica,san-serif" SIZE=-1>Customer service telephone number from back of
card.*</FONT><BR>
<FONT FACE="arial,helvetica,san-serif" SIZE=-2 COLOR="#FF0000">__CCPHONE_err__</FONT></TD>
<TD><INPUT TYPE="text" NAME="CCPHONE_inp" VALUE="__CCPHONE_inp__" SIZE="15"></TD>
</TR>
