test

 

<fieldset class=”webpay”>
<legend class=”webpay”>Order Info</legend>
<div class=”webpay”>
<span class=”webpay”>
<label for=”amount” class=”webpay”>Amount (add a $2 service fee)</label><input alt=”” name=”amount” class=”webpay” type=”text” value=”0.00″ size=”10″ >
</span>
</div>
<div class=”webpay”>
<span class=”webpay”>
<label for=”merchantordernumber” class=”webpay”>Policy Number</label><input alt=”” name=”merchantordernumber” class=”webpay” type=”text” value=”” size=”32″ >
</span>
</div>
<div class=”webpay”>
<span class=”webpay”>
<label for=”ci_email” class=”webpay”>Email</label><input alt=”” name=”ci_email” class=”webpay” type=”text” value=”” size=”32″ >
</span>
</div>
<div class=”webpay”>
<span class=”webpay”>
<label for=”ci_phone” class=”webpay”>Phone</label><input alt=”” name=”ci_phone” class=”webpay” type=”text” value=”” size=”11″ >
</span>
</div>
</fieldset>
<fieldset class=”webpay” style=”border:0;”>
<legend class=”webpay” style=”display:none”>Recurring Info</legend>
</fieldset>
<fieldset class=”webpay”>
<legend class=”webpay”>Address Info</legend>
<div class=”webpay”>
<span class=”webpay”>
<label for=”ci_billaddr1″ class=”webpay”>Billing Address</label><input alt=”” name=”ci_billaddr1″ class=”webpay” type=”text” value=”” size=”32″ >
</span>
</div>
<div class=”webpay”>
<span class=”webpay”>
<label for=”ci_billaddr2″ class=”webpay”>Billing Address 2</label><input alt=”” name=”ci_billaddr2″ class=”webpay” type=”text” value=”” size=”32″ >
</span>
</div>
<div class=”webpay”>
<span class=”webpay”>
<label for=”ci_billcity” class=”webpay”>Billing City</label><input alt=”” name=”ci_billcity” class=”webpay” type=”text” value=”” size=”32″ >
</span>
</div>
<div class=”webpay”>
<span class=”webpay”>
<label for=”ci_billstate” class=”webpay”>Billing State</label><select alt=”” name=”ci_billstate” size=”1″ class=”webpay”><option value=””>(Please select a 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=”AB”>Alberta</option><option value=”BC”>British Columbia</option><option value=”MB”>Manitoba</option><option value=”NB”>New Brunswick</option><option value=”NF”>Newfoundland</option><option value=”NT”>Northwest Territories</option><option value=”NS”>Nova Scotia</option><option value=”ON”>Ontario</option><option value=”PE”>Prince Edward Island</option><option value=”QC”>Quebec</option><option value=”SK”>Saskatchewan</option><option value=”YT”>Yukon</option></select>
</span>
</div>
<div class=”webpay”>
<span class=”webpay”>
<label for=”ci_billzip” class=”webpay”>Billing Zip</label><input alt=”” name=”ci_billzip” class=”webpay” type=”text” value=”” size=”11″ >
</span>
</div>
<div class=”webpay”>
<span class=”webpay”>
<label for=”ci_shipaddr1″ class=”webpay”>Ship To Address</label><input alt=”” name=”ci_shipaddr1″ class=”webpay” type=”text” value=”” size=”32″ >
</span>
</div>
<div class=”webpay”>
<span class=”webpay”>
<label for=”ci_shipaddr2″ class=”webpay”>Ship To Address 2</label><input alt=”” name=”ci_shipaddr2″ class=”webpay” type=”text” value=”” size=”32″ >
</span>
</div>
<div class=”webpay”>
<span class=”webpay”>
<label for=”ci_shipcity” class=”webpay”>Ship To City</label><input alt=”” name=”ci_shipcity” class=”webpay” type=”text” value=”” size=”32″ >
</span>
</div>
<div class=”webpay”>
<span class=”webpay”>
<label for=”ci_shipstate” class=”webpay”>Ship To State</label><select alt=”” name=”ci_shipstate” size=”1″ class=”webpay”><option value=””>(Please select a 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=”AB”>Alberta</option><option value=”BC”>British Columbia</option><option value=”MB”>Manitoba</option><option value=”NB”>New Brunswick</option><option value=”NF”>Newfoundland</option><option value=”NT”>Northwest Territories</option><option value=”NS”>Nova Scotia</option><option value=”ON”>Ontario</option><option value=”PE”>Prince Edward Island</option><option value=”QC”>Quebec</option><option value=”SK”>Saskatchewan</option><option value=”YT”>Yukon</option></select>
</span>
</div>
<div class=”webpay”>
<span class=”webpay”>
<label for=”ci_shipzip” class=”webpay”>Ship To Zip</label><input alt=”” name=”ci_shipzip” class=”webpay” type=”text” value=”” size=”11″ >
</span>
</div>
</fieldset>
<fieldset class=”webpay”>
<legend class=”webpay”>Payment Info</legend>
<div class=”webpay”>
<span class=”webpay”>
<label for=”ccname” class=”webpay”>Name On Card</label><input alt=”” name=”ccname” class=”webpay” type=”text” value=”” size=”32″ >
</span>
</div>
<div class=”webpay”>
<span class=”webpay”>
<label for=”ccnum” class=”webpay”>Card Number</label><input alt=”” name=”ccnum” class=”webpay” type=”text” value=”” size=”17″ >
</span>
</div>
<div class=”webpay”>
<span class=”webpay”>
<label for=”expmon” class=”webpay”>Expiry Date</label><select alt=”” name=”expmon” size=”1″ class=”webpay”><option value=”01″>01</option><option value=”02″>02</option><option value=”03″>03</option><option value=”04″>04</option><option value=”05″>05</option><option value=”06″>06</option><option value=”07″>07</option><option value=”08″>08</option><option value=”09″>09</option><option value=”10″>10</option><option value=”11″>11</option><option value=”12″>12</option></select>
</span>
<span class=”webpay”><select alt=”” name=”expyear” size=”1″ class=”webpay”><option value=”2010″>2010</option><option value=”2011″>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></select>
</span>
</div>
<div class=”webpay”>
<span class=”webpay”>
<label for=”cvv2″ class=”webpay”>CVV2/CVC2/CID</label><input alt=”” name=”cvv2″ class=”webpay” type=”text” value=”” size=”4″ >
</span>
</div>

</fieldset>