mirror of
https://github.com/OpenXE-org/OpenXE.git
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25 lines
734 B
Smarty
25 lines
734 B
Smarty
<form action="" method="post" name="eprooform">
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<table>
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<tr><td>Kreditkarte:</td><td><select name="typ">[TYP]</select></td>
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<td> </td>
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<td></td><td></td>
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</tr>
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<tr><td>Kreditkartennummer:</td><td><input type="text" name="kreditkarte" size="20" value="[KREDITKARTE]"></td>
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<td> </td>
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<td>Prüfnummer:</td><td><input type="text" name="pruefnummer" size="5" value="[PRUEFNUMMER]"> 3 Stellen von der Rückseite</td>
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</tr>
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<tr><td>Karteninhaber:</td><td><input type="text" name="inhaber" size="20" value="[INHABER]"></td>
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<td> </td>
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<td>Gültig bis:</td><td>
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<select name="monat">[MONAT]</select>
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<select name="jahr">[JAHR]</select>
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</td>
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</tr>
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</table>
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</form>
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<br><br>
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