<!-- 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>
