<html>
<head>
<title>arclab MailMe! Sample C - Order form with credit cards</title>
</head>
<body>

<form action="/cgi-bin/MailMe.exe" method="POST" name="Sample C">

<input type="hidden" name="MAILME_FROM" value="me@myserver.xxx">
<input type="hidden" name="MAILME_TO" value="feedback@myserver.xxx">
<input type="hidden" name="MAILME_SERVER" value="mail.myserver.xxx">
<input type="hidden" name="MAILME_SUBJECT" value="Order-form (Sample1)">
<input type="hidden" name="MAILME_SUCCESS" value="success.htm">
<input type="hidden" name="MAILME_REQUIRED" value="required.htm">
<input type="hidden" name="MAILME_ERROR" value="error.htm">
<input type="hidden" name="MAILME_BADCCCARD" value="badcard.htm">
<input type="hidden" name="MAILME_CCACCEPT" value="VISA,AMEX,MC">


<p><strong><u>Personal Information:</u></strong></p>
<table border="0" width="100%">
<tr>
<td>First name:</td>
<td><input type="text" size="35" name="_REQ_First_name">(required)</td>
</tr>
<tr>
<td>Init:</td>
<td><input type="text" size="35" name="Init"></td>
</tr>
<tr>
<td>Name:</td>
<td><input type="text" size="35" name="_REQ_Name">(required)</td>
</tr>
<tr>
<td>Address1:</td>
<td><input type="text" size="35" name="_REQ_Address1">(required)</td>
</tr>
<tr>
<td>Address2:</td>
<td><input type="text" size="35" name="Address2"></td>
</tr>
<tr>
<td>Zip:</td>
<td><input type="text" size="5" name="_REQ_Zip">(required)</td>
</tr>
<tr>
<td>City:</td>
<td><input type="text" size="35" name="_REQ_City">(required) </td>
</tr>
<tr>
<td>Country:</td>
<td><input type="text" size="35" name="_REQ_County">(required) </td>
</tr>
<tr>
<td>EMail:</td>
<td><input type="text" size="35" name="EMail"></td>
</tr>
</table>
<p> <strong><u>Order Information:</u></strong></p>
<table border="0" width="100%">
<tr>
<td>Quantity:</td>
<td><input type="text" size="5" name="_REQ_Quantity">(required)</td>
</tr>
<tr>
<td>Order Type: </td>
<td><select name="Order_type" size="1">
<option selected value="Product A ( 10 US$)">Product A ( 10 US$)</option>
<option value="Product B ( 20 US$)">Product B ( 20 US$)</option>
<option value="Product C ( 30 US$ )">Product C ( 30 US$ )</option>
</select></td>
</tr>
</table>

<p><strong><u>Credit Card information: (we accept VISA, AMEX and MASTERCARD)</u></strong></p>
<table border="0" width="100%">
<tr>
<td>Cardnumber:</td>
<td><input type="text" size="35" name="_REQ__CC_Cardnumber">(required)</td>
</tr>
<tr>
<td>Expires on:</td>
<td><input type="text" size="5" name="_REQ_Expiration_date">(required)</td>
</tr>
</table>

<p><input type="submit" name="_IGNORE_Send" value="Send"></p>
</form>

</body>
</html>