<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01//EN">
<html>
<head>
<title></title>
</head>
<body>
<form name="creditCardForm" method="post" action="#" id="creditCardForm">
<input type="hidden" name="CCForm.addNewCO" value="true">
<table>
<col width="135">
<col width="550">
<tr valign="top">
<td>
<img src="#" width="125" height="80" alt="">
<table>
<col width="65">
<col width="60">
<tr>
<td>
<img src="#" width="60" height="38" alt="">
</td>
<td>
<img src="#" width="60" height="38" alt="">
</td>
</tr>
<tr>
<td colspan="2" height="5"></td>
</tr>
<tr>
<td>
<img src="#" width="60" height="38" alt="">
</td>
<td>
<img src="#" width="60" height="38" alt="">
</td>
</tr>
</table>
</td>
<td>
<!-- begin billingPageCreditCards -->
<div class="BodyXLBold">
Pay With a Credit Card or Debit Card
</div>
<div class="BodyM">
Make the most of your shopping experience with the Walmart Discover® or Walmart Credit Card®. <a href="javascript:triggerChildOmniture('Pay%20with%20a%20Credit%20Card%20or%20Debit%20Card','Learn%20More');%20popupHelp('/cservice/contextual_help_popup.gsp?modId=447772',%20'',%20600,%20350);">Learn More</a> or <a href="/instantcredit/StartApplicationFromBilling.do">Apply Now</a>.<br>
Debit cards (also called check cards, ATM cards or bank cards) are accepted if they have a Visa or MasterCard logo.
</div><!-- end billingPageCreditCards -->
<table>
<col width="135">
<col width="415">
<tr>
<td class="BodyMBold">
Type of Card
</td>
<td class="BodyM">
<select name="CCForm.cardType">
<option value="">
Enter a new card
</option>
<option value="Wal-Mart Credit Card">
Wal-Mart Credit Card
</option>
<option value="Wal-Mart Discover">
Wal-Mart Discover
</option>
<option value="DISCOVER">
DISCOVER
</option>
<option value="VISA">
VISA
</option>
<option value="MASTERCARD">
MASTERCARD
</option>
<option value="AMEX">
AMEX
</option>
</select>
</td>
</tr>
<tr>
<td colspan="2" height="10"></td>
</tr><!-- CC Number -->
<tr>
<td class="BodyMBold">
Card number
</td>
<td class="BodyM">
<input type="text" name="CCForm.cardNumber" maxlength="125" size="16" value="">
</td>
</tr>
<tr>
<td colspan="2" height="10"></td>
</tr><!-- Expiration Date -->
<tr>
<td class="BodyMBold">
Expiration date
</td>
<td>
<select name="CCForm.expirationMonth">
<option value="1">
1
</option>
<option value="2">
2
</option>
<option value="3">
3
</option>
<option value="4">
4
</option>
<option value="5">
5
</option>
<option value="6">
6
</option>
<option value="7">
7
</option>
<option value="8">
8
</option>
<option value="9" selected="selected">
9
</option>
<option value="10">
10
</option>
<option value="11">
11
</option>
<option value="12">
12
</option>
</select> <select name="CCForm.expirationYear">
<option value="2011" selected="selected">
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>
</select>
</td>
</tr>
<tr>
<td></td>
<td class="BodyM">
Not required for Walmart Credit Card
</td>
</tr>
<tr>
<td colspan="2" height="10"></td>
</tr>
<tr>
<td class="BodyMBold">
Name as it appears on card
</td>
<td class="BodyM">
<input type="text" name="CCForm.name" size="20" value="">
</td>
</tr>
<tr>
<td colspan="2" height="10"></td>
</tr><!-- CID Editor -->
<tr valign="top">
<td class="BodyMBold">
Card Identification Number
</td>
<td class="BodyM">
<table>
<tr valign="top">
<td>
<input type="text" name="CCForm.cid" size="5" value="">
</td>
<td>
<img src="#" width="36" height="24" alt="">
</td>
<td>
<div class="BodyMBold">
Visa, MasterCard, Discover, Walmart Cards:
</div>
<div class="BodyM">
Last 3 digits on back of card.
</div>
</td>
</tr>
<tr>
<td colspan="3" height="5"></td>
</tr>
<tr valign="top">
<td></td>
<td>
<img src="#" width="36" height="24" alt="">
</td>
<td>
<div class="BodyMBold">
<span class="CheckoutBodyTextAccent">American Express:</span>
</div>
<div class="BodyM">
<span class="CheckoutBodyTextAccent">Last 4 digits in small print on front of card.</span>
</div>
</td>
</tr>
<tr>
<td></td>
<td colspan="2" class="BodyM">
<a href="#" onclick="triggerChildOmniture('Card Identification Number','Need Help?'); window.open('/cservice/cid_help_popup.gsp','cidhelp','width=550,height=650')">Need help?</a>
</td>
</tr>
</table>
</td>
</tr>
</table>
<h4>
Billing Address
</h4>
<p class="BodyM">
This address must match your credit card's billing address.
</p>
<div>
<input id="checkForBillingAddress" name="isBillingAddress" type="checkbox" onclick="javascript:clickBillCheckbox()"> <span class="BodyM">Same as Shipping address</span>
</div>
<table>
<col width="135">
<col width="415"><!-- Company Name -->
<tr>
<td class="BodyM">
Company Name
</td>
<td>
<input type="text" name="CCForm.companyName" maxlength="40" size="30" value=""> <span>(optional)</span>
</td>
</tr>
<tr>
<td colspan="2" height="7"></td>
</tr>
<tr>
<td colspan="2">
<!-- begin ccAddressFields -->
<table>
<col width="135">
<col width="260"><!-- STREET 1 -->
<tr>
<td class="BodyMBold">
Address Line 1
</td>
<td>
<input type="text" name="addressForm.street1" maxlength="125" size="30">
</td>
</tr>
<tr>
<td colspan="2" height="7"></td>
</tr><!-- STREET2 -->
<tr>
<td class="BodyM">
Address Line 2
</td>
<td>
<input type="text" name="addressForm.street2" maxlength="125" size="30"> <span>(optional)</span>
</td>
</tr>
<tr>
<td colspan="2" height="7"></td>
</tr><!-- CITY -->
<tr>
<td class="BodyMBold">
City
</td>
<td>
<input type="text" name="addressForm.city" maxlength="125" size="30">
</td>
</tr>
<tr>
<td colspan="2" height="7"></td>
</tr><!-- STATE -->
<tr>
<td class="BodyMBold">
State
</td>
<td>
<select name="addressForm.state">
<option value="">
Choose State
</option>
<option value="AL">
Alabama
</option>
<option value="AK">
Alaska
</option>
<option value="AZ">
Arizona
</option>
<option value="AR">
Arkansas
</option>
<option value="CA">
California
</option>
<option value="CO">
Colorado
</option>
<option value="CT">
Connecticut
</option>
<option value="DE">
Delaware
</option>
<option value="DC">
District Of Columbia
</option>
<option value="FL">
Florida
</option>
<option value="GA">
Georgia
</option>
<option value="HI">
Hawaii
</option>
<option value="ID">
Idaho
</option>
<option value="IL">
Illinois
</option>
<option value="IN">
Indiana
</option>
<option value="IA">
Iowa
</option>
<option value="KS">
Kansas
</option>
<option value="KY">
Kentucky
</option>
<option value="LA">
Louisiana
</option>
<option value="ME">
Maine
</option>
<option value="MD">
Maryland
</option>
<option value="MA">
Massachusetts
</option>
<option value="MI">
Michigan
</option>
<option value="MN">
Minnesota
</option>
<option value="MS">
Mississippi
</option>
<option value="MO">
Missouri
</option>
<option value="MT">
Montana
</option>
<option value="NE">
Nebraska
</option>
<option value="NV">
Nevada
</option>
<option value="NH">
New Hampshire
</option>
<option value="NJ">
New Jersey
</option>
<option value="NM">
New Mexico
</option>
<option value="NY">
New York
</option>
<option value="NC">
North Carolina
</option>
<option value="ND">
North Dakota
</option>
<option value="OH">
Ohio
</option>
<option value="OK">
Oklahoma
</option>
<option value="OR">
Oregon
</option>
<option value="PA">
Pennsylvania
</option>
<option value="RI">
Rhode Island
</option>
<option value="SC">
South Carolina
</option>
<option value="SD">
South Dakota
</option>
<option value="TN">
Tennessee
</option>
<option value="TX">
Texas
</option>
<option value="UT">
Utah
</option>
<option value="VT">
Vermont
</option>
<option value="VA">
Virginia
</option>
<option value="WA">
Washington
</option>
<option value="WV">
West Virginia
</option>
<option value="WI">
Wisconsin
</option>
<option value="WY">
Wyoming
</option>
<option value="AA">
Armed Forces Americas
</option>
<option value="AP">
Armed Forces Pacific
</option>
<option value="AE">
Armed Forces other
</option>
<option value="AS">
American Samoa
</option>
<option value="GU">
Guam
</option>
<option value="MP">
Northern Mariana Islands
</option>
<option value="PW">
Palau
</option>
<option value="PR">
Puerto Rico
</option>
<option value="VI">
Virgin Islands
</option>
</select>
</td>
</tr>
<tr>
<td colspan="2" height="7"></td>
</tr><!-- ZIP -->
<tr>
<td class="BodyMBold">
Zip Code
</td>
<td>
<input type="text" name="addressForm.zip" maxlength="20" size="10">
</td>
</tr>
<tr>
<td colspan="2" height="7"></td>
</tr><!-- PHONE -->
<tr>
<td class="BodyMBold">
Phone Number
</td>
<td>
<input type="text" name="addressForm.phone" maxlength="20" size="25"> <span class="BodyM">(Must be the number associated with your credit card)</span>
</td>
</tr>
</table><!-- end ccAddressFields -->
</td>
</tr>
<tr>
<td colspan="2" height="10"></td>
</tr>
<tr>
<td></td>
<td>
<input type="image" src="#" width="86" height="25" alt="Continue">
</td>
</tr>
</table>
</td>
</tr>
</table>
</form>
</body>
</html>
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