mirror of
https://github.com/OpenXE-org/OpenXE.git
synced 2024-11-15 20:47:15 +01:00
25 lines
734 B
Smarty
25 lines
734 B
Smarty
<form action="" method="post" name="eprooform">
|
|
<table>
|
|
|
|
<tr><td>Kreditkarte:</td><td><select name="typ">[TYP]</select></td>
|
|
<td> </td>
|
|
<td></td><td></td>
|
|
</tr>
|
|
|
|
<tr><td>Kreditkartennummer:</td><td><input type="text" name="kreditkarte" size="20" value="[KREDITKARTE]"></td>
|
|
<td> </td>
|
|
<td>Prüfnummer:</td><td><input type="text" name="pruefnummer" size="5" value="[PRUEFNUMMER]"> 3 Stellen von der Rückseite</td>
|
|
</tr>
|
|
|
|
<tr><td>Karteninhaber:</td><td><input type="text" name="inhaber" size="20" value="[INHABER]"></td>
|
|
<td> </td>
|
|
<td>Gültig bis:</td><td>
|
|
<select name="monat">[MONAT]</select>
|
|
<select name="jahr">[JAHR]</select>
|
|
</td>
|
|
</tr>
|
|
</table>
|
|
|
|
</form>
|
|
<br><br>
|