<!-- https://www.jbox.com/checkout/payment# -->
<form name="paymentForm" method="post" action="#" id="paymentForm">
<div id="errors"></div>
<fieldset id="paymentchoose">
<legend>Choose a payment method</legend>
<div>
<select id="paymentoption" accesskeyclass="element select medium" name="payment_method" onchange="changePayment()">
<option selected="selected">
Visa
</option>
<option>
Mastercard
</option>
<option>
American Express
</option>
<option>
Discover
</option>
<option>
Card on File (provide CVV2)
</option>
<option>
Check / Money Order
</option>
<option>
Gift Certificate / Credit
</option>
<option>
Western Union (we'll send instructions)
</option>
<option value="PayPal">
PayPal
</option>
<option value="Google Checkout">
Google Checkout
</option>
</select>
</div>
</fieldset>
<fieldset id="ccinput">
<legend>Credit Card Details</legend>
<div>
<input name="cc_number" class="element text medium" type="text" maxlength="255" value=""> <label for="address1"><b>Credit Card Number</b></label>
</div>
<div>
<input name="cc_name" class="element text medium" type="text" maxlength="60" value=""> <label for="address1">Name On Card | Ex: <i>Peter Payne</i></label>
</div>
<div class="left">
<span><input name="cc_exp" class="element text small" type="text" maxlength="255" value=""> <label for="cc_exp">Expiration date<br>
(MM/YY)</label></span>
</div>
<div>
<span><input name="cc_cvv2" class="element text small" type="text" maxlength="255" value=""> <label for="cc_cvv2">CVV2 / Security Code:</label></span>
</div>
</fieldset>
<fieldset>
<legend>If an item is not available:</legend> <select name="field_17">
<option value="Select an option...">
Select an option...
</option>
<option value="Cancel the item">
Cancel the item
</option>
<option value="Wait for all items to be available">
Wait for all items to be available
</option>
<option value="Split and send separately (additional fees apply)">
Split and send separately (additional fees apply)
</option>
</select>
</fieldset>
<fieldset>
<legend>Please confirm your age</legend> <input name="age" class="element text small" type="text" maxlength="255" value="">
</fieldset>
<fieldset>
<legend>Comment or Special Instructions (if any)</legend>
<textarea id="element_6" name="comments" class="element textarea small"></textarea>
</fieldset><input type="hidden" name="paymentForm" value="259215"> <input id="placeorder" class="button_text" type="submit" name="submit" value="Place Order">
</form>