<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
<HTML>
<HEAD>
<TITLE></TITLE>
</HEAD>
<BODY onload="javascript:creditForm.reset();" >
<H3>Sample CF5 Form</H3>
<CFFORM NAME="creditForm" ACTION="billCard.cfm" METHOD="POST" ENCTYPE="multipart/form-data">
<CFOUTPUT>
<TABLE WIDTH="85%" ALIGN="CENTER" CLASS="dark" CELLSPACING="0" CELLPADDING="3" BORDER="0">
<TR>
<td CLASS="dark" WIDTH="33%" ALIGN="LEFT"><font face="Arial, Helvetica, sans-serif">Order Reference
: </font></td>
<TD CLASS="light" width="1%"> </TD>
<TD CLASS="light" width="66%">
<cfinput type="TEXT" name="OrderRef" required="Yes" message="Order Reference">
</TD>
</TR>
<TR>
<td CLASS="dark" WIDTH="33%" ALIGN="LEFT"><font face="Arial, Helvetica, sans-serif">Amount
: </font></td>
<TD CLASS="light" width="1%">$</TD>
<TD CLASS="light" width="66%">
<cfinput type="TEXT" name="CrTotal" required="Yes" validate="Regular_expression" pattern="^(\+|-)?[1-9][0-9]*(\.[0-9]{2})?$" message="Please enter the amount.">
</TD>
</TR>
<TR>
<td CLASS="light" COLSPAN="3" ALIGN="LEFT"><font size="+1" face="Arial, Helvetica, sans-serif">Your
card details...</font></td>
</TR>
<TR>
<td CLASS="light" WIDTH="33%" ALIGN="LEFT"><font face="Arial, Helvetica, sans-serif">Card
Type : </font></td>
<TD CLASS="light" width="1%"> </TD>
<TD CLASS="light" width="66%">
<select name="CrType">
<option value="1">Visa</option>
<option value="2">Mastercard</option>
<option value="3">American Express</option>
</select>
</TD>
</TR>
<TR>
<td ALIGN="LEFT" CLASS="light" WIDTH="33%"><font face="Arial, Helvetica, sans-serif">Card
Number : </font></td>
<TD CLASS="light" width="1%"> </TD>
<TD CLASS="light" width="66%">
<cfinput type="TEXT" name="CrNumber" required="Yes" maxlength="16" message="Please enter a card number.">
</TD>
</TR>
<TR>
<td ALIGN="LEFT" CLASS="light" WIDTH="33%"><font face="Arial, Helvetica, sans-serif">Name
on card : </font></td>
<TD CLASS="light" width="1%"> </TD>
<TD CLASS="light" width="66%">
<cfinput type="TEXT" name="CrName" required="Yes" message="Please enter the name on your card.">
</TD>
</TR>
<TR>
<td ALIGN="LEFT" CLASS="light" WIDTH="33%">Expiry
Date : </td>
<TD CLASS="light" width="1%"> </TD>
<TD CLASS="light" width="66%">
<select name="CrMonth">
<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>
<select name="CrYear">
<option value="05">2005</option>
<option value="06">2006</option>
<option value="07">2007</option>
<option value="08">2008</option>
<option value="09">2009</option>
<option value="10">2010</option>
<option value="11">2011</option>
</select>
</TD>
</TR>
</TABLE>
<TABLE WIDTH="85%" ALIGN="CENTER" CLASS="light" CELLSPACING="0" CELLPADDING="0">
<TR>
<TD> </TD>
<TD STYLE="text-align:right" ALIGN="RIGHT">
<INPUT TYPE="SUBMIT" ID="submitbutton" WIDTH="104" HEIGHT="22" ALT="Continue" BORDER="0" >
</TD>
</TR>
</TABLE>
</CFOUTPUT>
</CFFORM>
</BODY>
</HTML>