Customer and cardholder variables

Required system variable

<input type="hidden" name="next_phase" value="paydata">

<input type="hidden" name="agree2terms" value="0">
 

Paytypes



<h2>Paytype*</h2>

<input type="radio" value="Visa" name="pay_type" />
<input type="radio" value="Visa Electron" name="pay_type" />
<input type="radio" value="Mastercard" name="pay_type" />
<input type="radio" value="Maestro" name="pay_type" />
<input type="radio" value="Eurocard" name="pay_type" />
<input type="radio" value="American Express" name="pay_type" />
<input type="radio" value="iDEAL" name="pay_type" />
 

Customer contact details


        <h3>Customer Name: *</h3>
<input type="text" name="cust_name" value="" size="40" maxlength="40" class="input">

        <h3>Company Name<br>(if applicable):</h3>
<input type="text" name="cust_company" value="" size="40" maxlength="40" class="input">

        <h3>Phone Number: *</h3>
<input type="text" name="cust_phone" value="" size="20" maxlength="20" class="input">

        <h3>Fax Number:</h3>
<input type="text" name="cust_fax" value="" size="20" maxlength="20" class="input">

        <h3>E-mail Address: *</h3>
<input type="text" name="cust_email" value="" size="40" maxlength="80" class="input" onDragStart="return false" onSelectStart="return false" onPaste="return false">

        <h3>Delivery/Mail/Business Address<br>(Incl. Zip/Postcode):</h3>
<textarea name="info1" cols="40" rows="3"></textarea>

 

Cardholder details


<h2>Cardholder address:</h2>

        <h3>Address line 1 (street address, p.o.box): *</h3>
<input type="text" name="cust_address1" value="" size="40" maxlength="60" class="input">

        <h3>Address line 2 (apartment, building, floor, etc.):</h3>
<input type="text" name="cust_address2" value="" size="30" maxlength="30" class="input">

        <h3>Zip/Postcode: *</h3>
<input type="text" name="cust_zip" value="" size="10" maxlength="10" class="input">

        <h3>City: *</h3>
<input type="text" name="cust_city" value="" size="30" maxlength="30" class="input">

<h3>State/County/Province:</h3>
<input type="text" name="cust_state" value="" size="20" maxlength="20" class="input">


<h2>Cardholder Country: *</h2>
<SELECT NAME="cust_country">
<OPTION VALUE="">(Select a country)</OPTION>
<OPTION VALUE="Afghanistan">Afghanistan</OPTION>
<OPTION VALUE="Åland Islands">Åland Islands</OPTION>
<OPTION VALUE="Albania">Albania</OPTION>
<OPTION VALUE="Algeria">Algeria</OPTION>
<OPTION VALUE="American Samoa">American Samoa</OPTION>
<OPTION VALUE="Andorra">Andorra</OPTION>

<OPTION VALUE="Angola">Angola</OPTION>
<OPTION VALUE="Anguilla">Anguilla</OPTION>
<OPTION VALUE="Antarctica">Antarctica</OPTION>
<OPTION VALUE="Antigua and Barbuda">Antigua and Barbuda</OPTION>
<OPTION VALUE="Argentina">Argentina</OPTION>
<OPTION VALUE="Armenia">Armenia</OPTION>
<OPTION VALUE="Aruba">Aruba</OPTION>
<OPTION VALUE="Australia">Australia</OPTION>
<OPTION VALUE="Austria">Austria</OPTION>

<OPTION VALUE="Azerbaijan">Azerbaijan</OPTION>
<OPTION VALUE="Bahamas">Bahamas</OPTION>
<OPTION VALUE="Bahrain">Bahrain</OPTION>
<OPTION VALUE="Bangladesh">Bangladesh</OPTION>
<OPTION VALUE="Barbados">Barbados</OPTION>
<OPTION VALUE="Belarus">Belarus</OPTION>
<OPTION VALUE="Belgium">Belgium</OPTION>
<OPTION VALUE="Belize">Belize</OPTION>
<OPTION VALUE="Benin">Benin</OPTION>

<OPTION VALUE="Bermuda">Bermuda</OPTION>
<OPTION VALUE="Bhutan">Bhutan</OPTION>
<OPTION VALUE="Bolivia, Plurinational State Of">Bolivia, Plurinational State Of</OPTION>
<OPTION VALUE="Bonaire, Sint Eustatius And Saba">Bonaire, Sint Eustatius And Saba</OPTION>
<OPTION VALUE="Bosnia and Herzegovina">Bosnia and Herzegovina</OPTION>
<OPTION VALUE="Botswana">Botswana</OPTION>
<OPTION VALUE="Bouvet Island">Bouvet Island</OPTION>
<OPTION VALUE="Brazil">Brazil</OPTION>
<OPTION VALUE="British Indian Ocean Territory">British Indian Ocean Territory</OPTION>

<OPTION VALUE="Brunei Darussalam">Brunei Darussalam</OPTION>
<OPTION VALUE="Bulgaria">Bulgaria</OPTION>
<OPTION VALUE="Burkina Faso">Burkina Faso</OPTION>
<OPTION VALUE="Burundi">Burundi</OPTION>
<OPTION VALUE="Cambodia">Cambodia</OPTION>
<OPTION VALUE="Cameroon">Cameroon</OPTION>
<OPTION VALUE="Canada">Canada</OPTION>
<OPTION VALUE="Cape Verde">Cape Verde</OPTION>
<OPTION VALUE="Cayman Islands">Cayman Islands</OPTION>

<OPTION VALUE="Central African Republic">Central African Republic</OPTION>
<OPTION VALUE="Chad">Chad</OPTION>
<OPTION VALUE="Chile">Chile</OPTION>
<OPTION VALUE="China">China</OPTION>
<OPTION VALUE="Christmas Island">Christmas Island</OPTION>
<OPTION VALUE="Cocos (Keeling) Islands">Cocos (Keeling) Islands</OPTION>
<OPTION VALUE="Colombia">Colombia</OPTION>
<OPTION VALUE="Comoros">Comoros</OPTION>
<OPTION VALUE="Congo">Congo</OPTION>

<OPTION VALUE="Congo, The Democratic Republic Of The">Congo, The Democratic Republic Of The</OPTION>
<OPTION VALUE="Cook Islands">Cook Islands</OPTION>
<OPTION VALUE="Costa Rica">Costa Rica</OPTION>
<OPTION VALUE="CÔte D'ivoire">CÔte D'ivoire</OPTION>
<OPTION VALUE="Croatia">Croatia</OPTION>
<OPTION VALUE="Cuba">Cuba</OPTION>
<OPTION VALUE="CuraÇao">CuraÇao</OPTION>
<OPTION VALUE="Cyprus">Cyprus</OPTION>
<OPTION VALUE="Czech Republic">Czech Republic</OPTION>

<OPTION VALUE="Denmark">Denmark</OPTION>
<OPTION VALUE="Djibouti">Djibouti</OPTION>
<OPTION VALUE="Dominica">Dominica</OPTION>
<OPTION VALUE="Dominican Republic">Dominican Republic</OPTION>
<OPTION VALUE="Ecuador">Ecuador</OPTION>
<OPTION VALUE="Egypt">Egypt</OPTION>
<OPTION VALUE="El Salvador">El Salvador</OPTION>
<OPTION VALUE="Equatorial Guinea">Equatorial Guinea</OPTION>
<OPTION VALUE="Eritrea">Eritrea</OPTION>

<OPTION VALUE="Estonia">Estonia</OPTION>
<OPTION VALUE="Ethiopia">Ethiopia</OPTION>
<OPTION VALUE="Falkland Islands (Malvinas)">Falkland Islands (Malvinas)</OPTION>
<OPTION VALUE="Faroe Islands">Faroe Islands</OPTION>
<OPTION VALUE="Fiji">Fiji</OPTION>
<OPTION VALUE="Finland">Finland</OPTION>
<OPTION VALUE="France">France</OPTION>
<OPTION VALUE="French Guiana">French Guiana</OPTION>
<OPTION VALUE="French Polynesia">French Polynesia</OPTION>

<OPTION VALUE="French Southern Territories">French Southern Territories</OPTION>
<OPTION VALUE="Gabon">Gabon</OPTION>
<OPTION VALUE="Gambia">Gambia</OPTION>
<OPTION VALUE="Georgia">Georgia</OPTION>
<OPTION VALUE="Germany">Germany</OPTION>
<OPTION VALUE="Ghana">Ghana</OPTION>
<OPTION VALUE="Gibraltar">Gibraltar</OPTION>
<OPTION VALUE="Greece">Greece</OPTION>
<OPTION VALUE="Greenland">Greenland</OPTION>

<OPTION VALUE="Grenada">Grenada</OPTION>
<OPTION VALUE="Guadeloupe">Guadeloupe</OPTION>
<OPTION VALUE="Guam">Guam</OPTION>
<OPTION VALUE="Guatemala">Guatemala</OPTION>
<OPTION VALUE="Guernsey">Guernsey</OPTION>
<OPTION VALUE="Guinea">Guinea</OPTION>
<OPTION VALUE="Guinea-bissau">Guinea-bissau</OPTION>
<OPTION VALUE="Guyana">Guyana</OPTION>
<OPTION VALUE="Haiti">Haiti</OPTION>

<OPTION VALUE="Heard Island and McDonald Islands">Heard Island and McDonald Islands</OPTION>
<OPTION VALUE="Holy See (vatican City State)">Holy See (vatican City State)</OPTION>
<OPTION VALUE="Honduras">Honduras</OPTION>
<OPTION VALUE="Hong Kong">Hong Kong</OPTION>
<OPTION VALUE="Hungary">Hungary</OPTION>
<OPTION VALUE="Iceland">Iceland</OPTION>
<OPTION VALUE="India">India</OPTION>
<OPTION VALUE="Indonesia">Indonesia</OPTION>
<OPTION VALUE="Iran, Islamic Republic Of">Iran, Islamic Republic Of</OPTION>

<OPTION VALUE="Iraq">Iraq</OPTION>
<OPTION VALUE="Ireland">Ireland</OPTION>
<OPTION VALUE="Isle of Man">Isle of Man</OPTION>
<OPTION VALUE="Israel">Israel</OPTION>
<OPTION VALUE="Italy">Italy</OPTION>
<OPTION VALUE="Jamaica">Jamaica</OPTION>
<OPTION VALUE="Japan">Japan</OPTION>
<OPTION VALUE="Jersey">Jersey</OPTION>
<OPTION VALUE="Jordan">Jordan</OPTION>

<OPTION VALUE="Kazakhstan">Kazakhstan</OPTION>
<OPTION VALUE="Kenya">Kenya</OPTION>
<OPTION VALUE="Kiribati">Kiribati</OPTION>
<OPTION VALUE="Korea, Democratic People's Republic Of">Korea, Democratic People's Republic Of</OPTION>
<OPTION VALUE="Korea, Republic Of">Korea, Republic Of</OPTION>
<OPTION VALUE="Kuwait">Kuwait</OPTION>
<OPTION VALUE="Kyrgyzstan">Kyrgyzstan</OPTION>
<OPTION VALUE="Lao People's Democratic Republic">Lao People's Democratic Republic</OPTION>
<OPTION VALUE="Latvia">Latvia</OPTION>

<OPTION VALUE="Lebanon">Lebanon</OPTION>
<OPTION VALUE="Lesotho">Lesotho</OPTION>
<OPTION VALUE="Liberia">Liberia</OPTION>
<OPTION VALUE="Liechtenstein">Liechtenstein</OPTION>
<OPTION VALUE="Lithuania">Lithuania</OPTION>
<OPTION VALUE="Luxembourg">Luxembourg</OPTION>
<OPTION VALUE="Lybia">Lybia</OPTION>
<OPTION VALUE="Macao">Macao</OPTION>
<OPTION VALUE="Macedonia, The Former Yugoslav Republic Of">Macedonia, The Former Yugoslav Republic Of</OPTION>

<OPTION VALUE="Madagascar">Madagascar</OPTION>
<OPTION VALUE="Malawi">Malawi</OPTION>
<OPTION VALUE="Malaysia">Malaysia</OPTION>
<OPTION VALUE="Maldives">Maldives</OPTION>
<OPTION VALUE="Mali">Mali</OPTION>
<OPTION VALUE="Malta">Malta</OPTION>
<OPTION VALUE="Marshall Islands">Marshall Islands</OPTION>
<OPTION VALUE="Martinique">Martinique</OPTION>
<OPTION VALUE="Mauritania">Mauritania</OPTION>

<OPTION VALUE="Mauritius">Mauritius</OPTION>
<OPTION VALUE="Mayotte">Mayotte</OPTION>
<OPTION VALUE="Mexico">Mexico</OPTION>
<OPTION VALUE="Micronesia, Federated States of">Micronesia, Federated States of</OPTION>
<OPTION VALUE="Moldova, Republic Of">Moldova, Republic Of</OPTION>
<OPTION VALUE="Monaco">Monaco</OPTION>
<OPTION VALUE="Mongolia">Mongolia</OPTION>
<OPTION VALUE="Montenegro">Montenegro</OPTION>
<OPTION VALUE="Montserrat">Montserrat</OPTION>

<OPTION VALUE="Morocco">Morocco</OPTION>
<OPTION VALUE="Mozambique">Mozambique</OPTION>
<OPTION VALUE="Myanmar">Myanmar</OPTION>
<OPTION VALUE="Namibia">Namibia</OPTION>
<OPTION VALUE="Nauru">Nauru</OPTION>
<OPTION VALUE="Nepal">Nepal</OPTION>
<OPTION VALUE="Netherlands">Netherlands</OPTION>
<OPTION VALUE="New Caledonia">New Caledonia</OPTION>
<OPTION VALUE="New Zealand">New Zealand</OPTION>

<OPTION VALUE="Nicaragua">Nicaragua</OPTION>
<OPTION VALUE="Niger">Niger</OPTION>
<OPTION VALUE="Nigeria">Nigeria</OPTION>
<OPTION VALUE="Niue">Niue</OPTION>
<OPTION VALUE="Norfolk Island">Norfolk Island</OPTION>
<OPTION VALUE="Northern Mariana Islands">Northern Mariana Islands</OPTION>
<OPTION VALUE="Norway">Norway</OPTION>
<OPTION VALUE="Oman">Oman</OPTION>
<OPTION VALUE="Pakistan">Pakistan</OPTION>

<OPTION VALUE="Palau">Palau</OPTION>
<OPTION VALUE="Palestinian Territory, Occupied">Palestinian Territory, Occupied</OPTION>
<OPTION VALUE="Panama">Panama</OPTION>
<OPTION VALUE="Papua New Guinea">Papua New Guinea</OPTION>
<OPTION VALUE="Paraguay">Paraguay</OPTION>
<OPTION VALUE="Peru">Peru</OPTION>
<OPTION VALUE="Philippines">Philippines</OPTION>
<OPTION VALUE="Pitcairn">Pitcairn</OPTION>
<OPTION VALUE="Poland">Poland</OPTION>

<OPTION VALUE="Portugal">Portugal</OPTION>
<OPTION VALUE="Puerto Rico">Puerto Rico</OPTION>
<OPTION VALUE="Qatar">Qatar</OPTION>
<OPTION VALUE="RÉunion">RÉunion</OPTION>
<OPTION VALUE="Romania">Romania</OPTION>
<OPTION VALUE="Russian Federation">Russian Federation</OPTION>
<OPTION VALUE="Rwanda">Rwanda</OPTION>
<OPTION VALUE="Saint BarthÉlemy">Saint BarthÉlemy</OPTION>
<OPTION VALUE="Saint Helena, Ascension And Tristan Da Cunha">Saint Helena, Ascension And Tristan Da Cunha</OPTION>

<OPTION VALUE="Saint Kitts and Nevis">Saint Kitts and Nevis</OPTION>
<OPTION VALUE="Saint Lucia">Saint Lucia</OPTION>
<OPTION VALUE="Saint Martin (french Part)">Saint Martin (french Part)</OPTION>
<OPTION VALUE="Saint Pierre and Miquelon">Saint Pierre and Miquelon</OPTION>
<OPTION VALUE="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</OPTION>
<OPTION VALUE="Samoa">Samoa</OPTION>
<OPTION VALUE="San Marino">San Marino</OPTION>
<OPTION VALUE="Sao Tome and Principe">Sao Tome and Principe</OPTION>
<OPTION VALUE="Saudi Arabia">Saudi Arabia</OPTION>

<OPTION VALUE="Senegal">Senegal</OPTION>
<OPTION VALUE="Serbia">Serbia</OPTION>
<OPTION VALUE="Seychelles">Seychelles</OPTION>
<OPTION VALUE="Sierra Leone">Sierra Leone</OPTION>
<OPTION VALUE="Singapore">Singapore</OPTION>
<OPTION VALUE="Sint Maarten (dutch Part)">Sint Maarten (dutch Part)</OPTION>
<OPTION VALUE="Slovakia">Slovakia</OPTION>
<OPTION VALUE="Slovenia">Slovenia</OPTION>
<OPTION VALUE="Solomon Islands">Solomon Islands</OPTION>

<OPTION VALUE="Somalia">Somalia</OPTION>
<OPTION VALUE="South Africa">South Africa</OPTION>
<OPTION VALUE="South Georgia And The South Sandwich Islands">South Georgia And The South Sandwich Islands</OPTION>
<OPTION VALUE="South Sudan">South Sudan</OPTION>
<OPTION VALUE="Spain">Spain</OPTION>
<OPTION VALUE="Sri Lanka">Sri Lanka</OPTION>
<OPTION VALUE="Sudan">Sudan</OPTION>
<OPTION VALUE="Suriname">Suriname</OPTION>
<OPTION VALUE="Svalbard And Jan Mayen">Svalbard And Jan Mayen</OPTION>

<OPTION VALUE="Swaziland">Swaziland</OPTION>
<OPTION VALUE="Sweden">Sweden</OPTION>
<OPTION VALUE="Switzerland">Switzerland</OPTION>
<OPTION VALUE="Syrian Arab Republic">Syrian Arab Republic</OPTION>
<OPTION VALUE="Taiwan, Province Of China">Taiwan, Province Of China</OPTION>
<OPTION VALUE="Tajikistan">Tajikistan</OPTION>
<OPTION VALUE="Tanzania, United Republic Of">Tanzania, United Republic Of</OPTION>
<OPTION VALUE="Thailand">Thailand</OPTION>
<OPTION VALUE="Timor-Leste">Timor-Leste</OPTION>

<OPTION VALUE="Togo">Togo</OPTION>
<OPTION VALUE="Tokelau">Tokelau</OPTION>
<OPTION VALUE="Tonga">Tonga</OPTION>
<OPTION VALUE="Trinidad and Tobago">Trinidad and Tobago</OPTION>
<OPTION VALUE="Tunisia">Tunisia</OPTION>
<OPTION VALUE="Turkey">Turkey</OPTION>
<OPTION VALUE="Turkmenistan">Turkmenistan</OPTION>
<OPTION VALUE="Turks and Caicos Islands">Turks and Caicos Islands</OPTION>
<OPTION VALUE="Tuvalu">Tuvalu</OPTION>

<OPTION VALUE="Uganda">Uganda</OPTION>
<OPTION VALUE="Ukraine">Ukraine</OPTION>
<OPTION VALUE="United Arab Emirates">United Arab Emirates</OPTION>
<OPTION VALUE="United Kingdom">United Kingdom</OPTION>
<OPTION VALUE="United States">United States</OPTION>
<OPTION VALUE="United States Minor Outlying Islands">United States Minor Outlying Islands</OPTION>
<OPTION VALUE="Uruguay">Uruguay</OPTION>
<OPTION VALUE="Uzbekistan">Uzbekistan</OPTION>
<OPTION VALUE="Vanuatu">Vanuatu</OPTION>

<OPTION VALUE="Venezuela, Bolivarian Republic Of">Venezuela, Bolivarian Republic Of</OPTION>
<OPTION VALUE="Viet Nam">Viet Nam</OPTION>
<OPTION VALUE="Virgin Islands, British">Virgin Islands, British</OPTION>
<OPTION VALUE="Virgin Islands, U.S.">Virgin Islands, U.S.</OPTION>
<OPTION VALUE="Wallis And Futuna">Wallis And Futuna</OPTION>
<OPTION VALUE="Western Sahara">Western Sahara</OPTION>
<OPTION VALUE="Yemen">Yemen</OPTION>
<OPTION VALUE="Zambia">Zambia</OPTION>
<OPTION VALUE="Zimbabwe">Zimbabwe</OPTION>

</SELECT>