<!-- https://quality-s.qvc.com/qic/qvcapp.aspx/view.1/app.multi/params.file.%7CCheckout%7CShipMethod,plex -->
<form method="post" id="frmPaymentMethod" name="PaymentMethod" action="#">
<div style="display:none;">
<input type="hidden" name="NextURL" value="PaymentMethod.plex">
<input type="hidden" name="RefererForm" value="PaymentMethod">
<input type="hidden" name="WildCardCreditSw">
<input type="hidden" name="NewMemberSw" id="NewMemberSw" value="0">
<input type="hidden" name="Command">
<input type="hidden" name="QSDiscountType">
<input type="hidden" name="QSDiscountAmount">
<input type="hidden" name="QSNextDiscountAmount">
<input type="hidden" name="QSDiscountLimit">
<input type="hidden" name="MyShowNewCardSw" value="1">
<input type="hidden" name="MyNumErr">
<input type="hidden" name="OrigEmailAddress" value="[email protected]">
<input type="hidden" name="ExpiredCreditCardExpYYMM">
<input type="hidden" name="SelectedCreditTerms" id="SelectedCreditTerms">
<input type="hidden" name="MustVerifySelection" id="MustVerifySelection" value="0">
<input type="hidden" name="CreditTermLinesSelectedBackButtonCase" id="CreditTermLinesSelectedBackButtonCase">
<input type="hidden" name="ElecGiftCardOnly" id="ElecGiftCardOnly">
</div>
<div class="paymentMethod" id="errorToggle_PayMeth">
<p class="pad">
<strong>Total Purchase (including tax and S&H): $276.40</strong><br>
Please select a payment method below. If you choose to enter a new card, you will be prompted to enter card type, number and expiration date.
</p>
</div><!-- end of total/credit paymentMethod div -->
<br>
<!-- begin creditterms loop -->
<!-- end of creditterms loop -->
<div class="paymentMethod">
<!-- start of credit card list - paymentMethod div -->
<p class="pad">
<strong>Payment Methods</strong>
</p>
<div class="paymentBgShade" id="bml_0">
<table class="creditNames">
<tr>
<td width="5">
<input type="radio" tabindex="0" id="PaymentMethod" name="PaymentMethod" value="BL">
</td>
<td width="210">
Bill Me Later<sup class="reg">®</sup>
</td>
<td colspan="3">
<a target="_blank" href="#" title="See Terms">See Terms</a>
</td>
</tr>
</table>
<div id="bmltoggle" class="bmltoggle">
<table cellpadding="0" cellspacing="0" border="0">
<tr>
<td>
<div class="col1">
<ol class="bmlform">
<li class="bmltxt">
<span class="note">Please enter confirmation information below:</span><br>
Bill Me Later<sup class="reg">®</sup> is subject to credit approval. For verification purposes, please provide your date of birth and the last four digits of your social security number.<br>
</li>
<li>
<div id="trHomePhone">
<label><em>*</em> Home Phone:</label> <input type="text" name="txtHomePhone1" size="3" class="inputbox" maxlength="3" value=""> <input type="text" name="txtHomePhone2" size="3" class="inputbox" maxlength="3" value=""> <input type="text" name="txtHomePhone3" size="4" class="inputbox" maxlength="4" value="">
</div>
<div class="labelerror" id="BMLPhoneErrorMsg"></div>
</li>
<li>
<div id="trEmail">
<label><em>*</em> Email Address:</label> <input type="text" name="txtEmail" class="inputbox" size="28" maxlength="48">
</div>
<div class="labelerror" id="BMLEmailErrorMsg"></div>
</li>
<li>
<div id="trSSN">
<label><em>*</em> Social Security Number:</label> XXX-XX-<input type="text" name="txtSSN" size="4" class="inputbox" maxlength="4"> Last 4 digits only
</div>
<div class="labelerror" id="BMLSSNErrorMsg"></div>
</li>
<li>
<div id="trDOB">
<label><em>*</em> Date of Birth:</label> <select name="selBirthMonth" id="birthMonth" class="inputbox">
<option value="Month">
Month
</option>
<option value="01">
January
</option>
<option value="02">
February
</option>
<option value="03">
March
</option>
<option value="04">
April
</option>
<option value="05">
May
</option>
<option value="06">
June
</option>
<option value="07">
July
</option>
<option value="08">
August
</option>
<option value="09">
September
</option>
<option value="10">
October
</option>
<option value="11">
November
</option>
<option value="12">
December
</option>
</select> <select name="selBirthDate" id="birthDate" class="inputbox">
<option value="Date">
Date
</option>
</select> <select name="selBirthYear" id="birthYear" class="inputbox">
<option value="Year">
Year
</option>
</select>
</div>
<div class="labelerror" id="BMLBirthdateErrorMsg"></div>
</li>
<li class="bmltxt">
<span class="note">E-sign Consent and Terms and Conditions:</span>
<div>
You must read the E-sign Consent section of the Terms and Conditions prior to checking the box below.
</div>
</li>
<li class="bmlagree">
<em>*</em> <input type="checkbox" name="chkTAC"> I agree to have the <a target="_blank" href="#">Terms and Conditions</a> presented electronically.
</li>
<li style="list-style: none">
<div class="labelerror" id="BMLTACErrorMsg"></div>
</li>
<li>
<em>*</em> Required Fields
</li>
</ol>
</div><!-- col1 END -->
</td>
</tr>
</table>
</div><!-- bmltoggle END -->
</div><!-- paymentNoShade END -->
<div class="paymentNoShade" id="paymentCheck">
<table class="creditNames">
<tr>
<td width="5">
<input type="radio" id="PaymentMethod" name="PaymentMethod" value="CK">
</td>
<td>
Check / Money Order
</td>
</tr>
</table><!-- <div class="clear"></div> -->
</div>
<div class="paymentBgShade" id="paymentNewCard">
<table class="creditNames">
<tr>
<td width="5">
<input type="radio" name="PaymentMethod" value="AddNew" id="radioNew" checked="checked">
</td>
<td>
Enter New Card:
</td>
</tr>
</table>
<div id="newcardtoggle" class="newcardtoggle">
<ol>
<li>
<label>Type:</label> <select id="cardType" name="cardType" class="inputbox">
<option value="VI">
Visa
</option>
<option value="MC">
MasterCard
</option>
<option value="SI">
Discover Network
</option>
<option value="AX">
American Express
</option>
<option value="QV">
QCard
</option>
<option value="CB">
Carte Blanche
</option>
<option value="DC">
Diners Club
</option>
</select>
</li>
<li>
<label>Number:</label><input type="text" maxlength="18" name="CreditCardNumber" class="inputbox">
</li>
<li>
<div id="date_line">
<label>Expiration:</label> <select name="CreditCardExpYYMM" class="inputbox">
<option value="092011">
09/2011
</option>
<option value="102011">
10/2011
</option>
<option value="112011">
11/2011
</option>
<option value="122011">
12/2011
</option>
<option value="012012">
01/2012
</option>
<option value="022012">
02/2012
</option>
<option value="032012">
03/2012
</option>
<option value="042012">
04/2012
</option>
<option value="052012">
05/2012
</option>
<option value="062012">
06/2012
</option>
<option value="072012">
07/2012
</option>
<option value="082012">
08/2012
</option>
<option value="092012">
09/2012
</option>
<option value="102012">
10/2012
</option>
<option value="112012">
11/2012
</option>
<option value="122012">
12/2012
</option>
<option value="012013">
01/2013
</option>
<option value="022013">
02/2013
</option>
<option value="032013">
03/2013
</option>
<option value="042013">
04/2013
</option>
<option value="052013">
05/2013
</option>
<option value="062013">
06/2013
</option>
<option value="072013">
07/2013
</option>
<option value="082013">
08/2013
</option>
<option value="092013">
09/2013
</option>
<option value="102013">
10/2013
</option>
<option value="112013">
11/2013
</option>
<option value="122013">
12/2013
</option>
<option value="012014">
01/2014
</option>
<option value="022014">
02/2014
</option>
<option value="032014">
03/2014
</option>
<option value="042014">
04/2014
</option>
<option value="052014">
05/2014
</option>
<option value="062014">
06/2014
</option>
<option value="072014">
07/2014
</option>
<option value="082014">
08/2014
</option>
<option value="092014">
09/2014
</option>
<option value="102014">
10/2014
</option>
<option value="112014">
11/2014
</option>
<option value="122014">
12/2014
</option>
<option value="012015">
01/2015
</option>
<option value="022015">
02/2015
</option>
<option value="032015">
03/2015
</option>
<option value="042015">
04/2015
</option>
<option value="052015">
05/2015
</option>
<option value="062015">
06/2015
</option>
<option value="072015">
07/2015
</option>
<option value="082015">
08/2015
</option>
<option value="092015">
09/2015
</option>
<option value="102015">
10/2015
</option>
<option value="112015">
11/2015
</option>
<option value="122015">
12/2015
</option>
<option value="012016">
01/2016
</option>
<option value="022016">
02/2016
</option>
<option value="032016">
03/2016
</option>
<option value="042016">
04/2016
</option>
<option value="052016">
05/2016
</option>
<option value="062016">
06/2016
</option>
<option value="072016">
07/2016
</option>
<option value="082016">
08/2016
</option>
<option value="092016">
09/2016
</option>
<option value="102016">
10/2016
</option>
<option value="112016">
11/2016
</option>
<option value="122016">
12/2016
</option>
<option value="012017">
01/2017
</option>
<option value="022017">
02/2017
</option>
<option value="032017">
03/2017
</option>
<option value="042017">
04/2017
</option>
<option value="052017">
05/2017
</option>
<option value="062017">
06/2017
</option>
<option value="072017">
07/2017
</option>
<option value="082017">
08/2017
</option>
<option value="092017">
09/2017
</option>
<option value="102017">
10/2017
</option>
<option value="112017">
11/2017
</option>
<option value="122017">
12/2017
</option>
<option value="012018">
01/2018
</option>
<option value="022018">
02/2018
</option>
<option value="032018">
03/2018
</option>
<option value="042018">
04/2018
</option>
<option value="052018">
05/2018
</option>
<option value="062018">
06/2018
</option>
<option value="072018">
07/2018
</option>
<option value="082018">
08/2018
</option>
<option value="092018">
09/2018
</option>
<option value="102018">
10/2018
</option>
<option value="112018">
11/2018
</option>
<option value="122018">
12/2018
</option>
<option value="012019">
01/2019
</option>
<option value="022019">
02/2019
</option>
<option value="032019">
03/2019
</option>
<option value="042019">
04/2019
</option>
<option value="052019">
05/2019
</option>
<option value="062019">
06/2019
</option>
<option value="072019">
07/2019
</option>
<option value="082019">
08/2019
</option>
<option value="092019">
09/2019
</option>
<option value="102019">
10/2019
</option>
<option value="112019">
11/2019
</option>
<option value="122019">
12/2019
</option>
<option value="012020">
01/2020
</option>
<option value="022020">
02/2020
</option>
<option value="032020">
03/2020
</option>
<option value="042020">
04/2020
</option>
<option value="052020">
05/2020
</option>
<option value="062020">
06/2020
</option>
<option value="072020">
07/2020
</option>
<option value="082020">
08/2020
</option>
<option value="092020">
09/2020
</option>
<option value="102020">
10/2020
</option>
<option value="112020">
11/2020
</option>
<option value="122020">
12/2020
</option>
<option value="012021">
01/2021
</option>
<option value="022021">
02/2021
</option>
<option value="032021">
03/2021
</option>
<option value="042021">
04/2021
</option>
<option value="052021">
05/2021
</option>
<option value="062021">
06/2021
</option>
<option value="072021">
07/2021
</option>
<option value="082021">
08/2021
</option>
</select>
</div>
</li>
<li>
<div id="cvv_line">
<label>Security Code:</label> <input type="text" name="CVV" size="4" class="inputbox" maxlength="4"> <a href="#" class="smoothbox third">What is this?</a>
</div>
</li>
</ol><!-- <div class="clear"></div> -->
</div><!-- <div class="clear"></div> -->
</div>
</div><br>
<div class="paymentMethod">
<div id="giftCard">
<p class="pad">
<strong>QVC Gift Cards</strong><br>
<input type="checkbox" id="giftCardBox" name="useGiftCard"> Use a Gift Card.
</p>
</div>
<div id="giftCardExpand" class="giftCardExpand">
<p class="pad">
If you wish to use more than one Gift Card, enter the first card number and Security ID Number and click the "Enter Another Card" button. If not, enter your card number and Security ID Number and click the "Continue Check-Out" button below.
</p>
<ol>
<li>
<label>Card Number:</label><input type="text" name="GiftCardNum" size="20" class="inputbox">
</li>
<li>
<label>Security ID Number:</label><input type="text" name="GiftCardPIN" size="5" class="inputbox" onkeyup="return SelectDefaultButton(this,4);"> <input type="image" id="RedeemGiftCard" name="RedeemGiftCard" src="#" alt="Enter Another Card">
</li>
</ol>
<p class="pad">
Gift Cards you enter will be converted to QVC Credit and stored on your account. If your Gift Card does not cover your total purchase, the outstanding balance due will be charged to the credit card you selected above. <a href="#" class="smoothbox third">Learn more about Gift Cards</a>.
</p><input type="hidden" name="RedeemedGiftCardSw">
</div>
<div class="clear"></div>
</div><br>
<div id="cancelContinue">
<div class="buttonsDiv">
<input type="image" id="continue" name="Continue" src="#" alt="Continue Check-Out"> <a href="#" class="primary" title="Cancel Order"><img src="#" alt="Cancel Order" width="103" height="19"></a>
</div>
</div>
</form>
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