<form action="https://secure.authorize.net/gateway/transact.dll" method="post"> <tr> <td colspan="2" align="center" class="normal_heading_center">Credit Card Information</td> </tr> <tr> <td class="normal">Credit Card Type </td> <td> <INPUT TYPE="HIDDEN" NAME="x_ADC_Relay_Response" VALUE="true"> <INPUT TYPE ="HIDDEN" NAME = "store_id" VALUE = "<tmpl_var store_id>"> <INPUT TYPE="HIDDEN" NAME="x_Login" VALUE="<tmpl_var x_Login>"> <INPUT TYPE="HIDDEN" NAME="x_Amount" VALUE="<tmpl_var cost>"> <input type="hidden" name="x_Last_Name" value="<tmpl_var lname>"> <input type="hidden" name="x_First_Name" value="<tmpl_var fname>"> <input type="hidden" name="x_Address" value="<tmpl_var address>"> <input type="hidden" name="x_City" value="<tmpl_var city>"> <input type="hidden" name="x_State" value="islamabad"> <input type="hidden" name="x_Zip" value="<tmpl_var zip>"> <input type="hidden" name="x_Country" value="<tmpl_var state>"> <input type="hidden" name="x_Company" value=""> <input type="hidden" name="x_Phone" value="<tmpl_var phone>"> <input type="hidden" name="x_Fax" value="<tmpl_var fax>"> <input type="hidden" name="x_Email" value="<tmpl_var email>"> <input type="hidden" name="x_Invoice_Num" value="<tmpl_var invoice_num>"> <input type="hidden" name="x_Description" value="Online Order"> <input type="hidden" name="x_Cust_ID" value="<tmpl_var custid>"> <select name="18-type_of_card" class="input-txt"> <option> MasterCard </option> <option> Visa </option> </select> </td> </tr> <tr> <td class="normal">Credit Card Number </td> <td> <input name="x_card_num" type="text" class="input-txt" size="20" maxlength="20"> </td> </tr> <tr> <td class="normal">Card Expiration: (MM/DD/YYYY)</td> <td> <INPUT NAME="x_exp_date" TYPE=TEXT class="input-txt" size="20"> </td> </tr> <tr> <td colspan=2 align="center"> <input type="submit" class="button" value="Submit"> <input name="Reset" type="reset" class="button" value="Reset"> </td> </tr> </form>