<TR><TD>

  <TABLE BORDER=0 WIDTH="550">
    <TR>
	<TD COLSPAN=3 align=center bgcolor="#93D5BE">
		<FONT SIZE=+1><B>Payment Information</B></FONT>
	</TD>
    </TR>

    <TR>
        <TD COLSPAN="3">
            <FONT COLOR="RED">
                <B>
                    Please ensure you are obtaining payment with the
                    information gathered.  This template does no credit card
                    processing by default.
                </B>
            </FONT>
        </TD>
    </TR>

    <TR>
	<TD align=right bgcolor="#93D5BE"><B>Method of Payment:</B></TD>
	<TD align=left>
		<select name="p_cc_type">
			<option value="visa" selected>Visa
			<option value="mastercard">Mastercard
			<option value="amex">American Express
			<option value="discover">Discover
		</select>
	</TD>
	<TD bgcolor="#93D5BE" align=center><B>Expiration Date</B></TD>
    </TR>
    
    <TR>
	<TD align=right bgcolor="#93D5BE"><B>Card Number:</B></TD>
	<TD align=left><input name="p_cc_num" size=20 value=""></TD>
	<TD align=left>

		<select name="p_cc_exp_mon">
			<option selected value="1">01
			<option value="2">02
			<option value="3">03
			<option value="4">04
			<option value="5">05
			<option value="6">06
			<option value="7">07
			<option value="8">08
			<option value="9">09
			<option value="10">10
			<option value="11">11
			<option value="12">12
		</select>
		&nbsp;

		<select name="p_cc_exp_yr">
			{{CC_YEARS}}
		</select>

	</TD>
    </TR>
  </TABLE>

</TD></TR>

