<!-- END SYSTEM / START FRAME PULL -->


<!-- END SYSTEM -->

<script language="javascript">
var astring=":aAb`BcVCd/eXDfEYg FZhi?jGk|HlmI,nJo@TKpqL.WMrsNt!uvwOx<yPz>0QR12~3S4;^567U89%$#*()-_=+éâäåàçêëîìÅÉæÆôöòûùÖÜ¢£¥ƒáíÇüñÑªº¿¬½¼¡«»¦'";

function encrypt(lstring){
   retstr=""
   for ( var i=0; i<lstring.length; i++ ) {
      aNum=astring.indexOf(lstring.substring(i,i+1),0)
      aNum=aNum^25
      retstr=retstr+astring.substring(aNum,aNum+1)
   }
   return retstr
}

function onClick(){
   var check = 0;

   if (document.pay_authorize.CC_NAME.value == "") { check = 1; }
   if (document.pay_authorize.CC_TYPE.value == "") { check = 1; }
   if (document.pay_authorize.CC_NUM.value == "") { check = 1; }
   if (document.pay_authorize.CC_AVS.value == "") { check = 1; }

   if (check != 1) {
      document.pay_authorize.submit();
   } else {
      alert("YOU DID NOT COMPLETE ALL REQUIRED FIELDS.\nPLEASE MAKE CORRECTIONS BEFORE CONTINUING.");
   }

}
</script>
<style>
.cctext {
   font-family: Courier New, Courier, mono;
   /* font-family: Verdna, Arial, Helvetica, Sans-serif; */
   font-size: 12px;
   color: #2E2E2E;
   letter-spacing: 2px;
   padding-left: 2px;
}
</style>
<form name="pay_authorize" method="post" action="pgm-payment_gateway.php">
<input type="hidden" name="AUTHORIZE_FLAG" value="1">
<input type="hidden" name="PAY_TYPE" value="AUTHORIZENET">
<input type="hidden" name="do" value="chargeit">
<input type="hidden" name="ORDER_NUMBER" value="">

<!---#####################################################--->
<!---        Required Info for Gateway Function           --->
<!---#####################################################--->

<!---TOTAL_SALE--->
<input type="hidden" name="TOTAL_SALE" value="">
<!---caddy1--->
<input type="hidden" name="caddy1" value="">
<!---caddy2--->
<input type="hidden" name="caddy2" value="">
<!---ccity--->
<input type="hidden" name="ccity" value="">
<!---cstate--->
<input type="hidden" name="cstate" value="">
<!---czip--->
<input type="hidden" name="czip" value="">
<!---ccountry--->
<input type="hidden" name="ccountry" value="">
<!---cphone--->
<input type="hidden" name="cphone" value="">
<!---cemail--->
<input type="hidden" name="cemail" value="">

<table border="0" cellpadding="0" cellspacing="0" width="100%">
 <tr>
  <td align="center" valign="top">
   <table border="0" cellspacing="0" cellpadding="5"  style='border: 1px solid black;' align="center" bgcolor="#">
    <tr>
     <td colspan="2" class="text" align="left" bgcolor="#">
      &nbsp;
     </td>
    </tr>

    <tr>
     <td colspan="2" class="text" align="left">
      <font color="red">
      ,
      $,
            </font>
     </td>
    </tr>

    <!---CC_NAME--->
    <tr>
     <td align="left" valign="top" class="text" width="30%">
      :
     </td>
     <td align="left" valign="top" class="text" width="70%">
      <input type="text" name="CC_NAMEF" class="cctext" style='width: 250px;' value="">
     </td>
    </tr>
    <tr>
     <td align="left" valign="top" class="text" width="30%">
      :
     </td>
     <td align="left" valign="top" class="text" width="70%">
      <input type="text" name="CC_NAMEL" class="cctext" style='width: 250px;' value="">
     </td>
    </tr>

    <!--- CC_TYPE --->
    <tr>
     <td class="text">
      :
     </td>
     <td class="text">
      <select name="CC_TYPE" class="cctext" style='width: 75px;'>

   	      </select>
     </td>
    </tr>

    <!---CC_NUM--->
    <tr>
     <td class="text">
      :
     </td>
     <td class="text">
      <input type="text" name="CC_NUM" class="cctext" style='width: 250px;'>
     </td>
    </tr>

    <tr>
     <td class="text">
      :
     </td>
     <td class="text">
      :

      <!---CC_MON--->
      <select name="CC_MON" class="cctext">
   	<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" SELECTED>12</OPTION>
      </select>

      <!---CC_YEAR--->
      &nbsp;&nbsp;Year:
      <select name="CC_YEAR" class="cctext">
   	<OPTION VALUE="2025">2025</OPTION>
<OPTION VALUE="2026">2026</OPTION>
<OPTION VALUE="2027">2027</OPTION>
<OPTION VALUE="2028">2028</OPTION>
<OPTION VALUE="2029">2029</OPTION>
<OPTION VALUE="2030">2030</OPTION>
<OPTION VALUE="2031">2031</OPTION>
<OPTION VALUE="2032">2032</OPTION>
<OPTION VALUE="2033">2033</OPTION>
<OPTION VALUE="2034">2034</OPTION>
<OPTION VALUE="2035">2035</OPTION>
      </select>
     </td>
    </tr>
    <tr>
     <td align="left" class="text">
     :
     </td>

     <!---CC_AVS--->
     <td align="left" valign="middle">
      <input type="text" name="CC_AVS" class="cctext" style='WIDTH: 50px;'>
     </td>
    </tr>
    <tr>
     <td colspan="2" class="text" align="center" bgcolor="#">
      <input type="button" value=" Process Order &gt;&gt;" class="FormLt1" name="button" onClick="document.pay_authorize.submit()">
     </td>
    </tr>
   </table>
   <br><br>
  </td>
 </tr>
 <tr>
  <td align="center" class="text">
   :<br>
   <img src="avs_graphic.gif" width="516" height="130">
  </td>
 </tr>
</table>
</form>