<form action="" method="post" name="eprooform">
	<table>

	<tr><td>Kreditkarte:</td><td><select name="typ">[TYP]</select></td>
	<td>&nbsp;</td>
	<td></td><td></td>
	</tr>

	<tr><td>Kreditkartennummer:</td><td><input type="text" name="kreditkarte" size="20" value="[KREDITKARTE]"></td>
	<td>&nbsp;</td>
	<td>Pr&uuml;fnummer:</td><td><input type="text" name="pruefnummer" size="5" value="[PRUEFNUMMER]">&nbsp; 3 Stellen von der R&uuml;ckseite</td>
	</tr>

	<tr><td>Karteninhaber:</td><td><input type="text" name="inhaber" size="20" value="[INHABER]"></td>
	<td>&nbsp;</td>
	<td>G&uuml;ltig bis:</td><td>
	<select name="monat">[MONAT]</select>&nbsp;
	<select name="jahr">[JAHR]</select>&nbsp;
	</td>
	</tr>
	</table>

  </form>
<br><br>