chrome/test/data/autofill/heuristics/input/16_crbug_93595.html

   1 <!-- https://www.jbox.com/checkout/payment# -->
   2 <form name="paymentForm" method="post" action="#" id="paymentForm">
   3   <div id="errors"></div>
   4   <fieldset id="paymentchoose">
   5     <legend>Choose a payment method</legend>
   6     <div>
   7       <select id="paymentoption" accesskeyclass="element select medium" name="payment_method" onchange="changePayment()">
   8         <option selected="selected">
   9           Visa
  10         </option>
  11         <option>
  12           Mastercard
  13         </option>
  14         <option>
  15           American Express
  16         </option>
  17         <option>
  18           Discover
  19         </option>
  20         <option>
  21           Card on File (provide CVV2)
  22         </option>
  23         <option>
  24           Check / Money Order
  25         </option>
  26         <option>
  27           Gift Certificate / Credit
  28         </option>
  29         <option>
  30           Western Union (we'll send instructions)
  31         </option>
  32         <option value="PayPal">
  33           PayPal
  34         </option>
  35         <option value="Google Checkout">
  36           Google Checkout
  37         </option>
  38       </select>
  39     </div>
  40   </fieldset>
  41   <fieldset id="ccinput">
  42     <legend>Credit Card Details</legend>
  43     <div>
  44       <input name="cc_number" class="element text medium" type="text" maxlength="255" value=""> <label for="address1"><b>Credit Card Number</b></label>
  45     </div>
  46     <div>
  47       <input name="cc_name" class="element text medium" type="text" maxlength="60" value=""> <label for="address1">Name On Card | Ex: <i>Peter Payne</i></label>
  48     </div>
  49     <div class="left">
  50       <span><input name="cc_exp" class="element text small" type="text" maxlength="255" value=""> <label for="cc_exp">Expiration date<br>
  51       (MM/YY)</label></span>
  52     </div>
  53     <div>
  54       <span><input name="cc_cvv2" class="element text small" type="text" maxlength="255" value=""> <label for="cc_cvv2">CVV2 / Security Code:</label></span>
  55     </div>
  56   </fieldset>
  57   <fieldset>
  58     <legend>If an item is not available:</legend> <select name="field_17">
  59       <option value="Select an option...">
  60         Select an option...
  61       </option>
  62       <option value="Cancel the item">
  63         Cancel the item
  64       </option>
  65       <option value="Wait for all items to be available">
  66         Wait for all items to be available
  67       </option>
  68       <option value="Split and send separately (additional fees apply)">
  69         Split and send separately (additional fees apply)
  70       </option>
  71     </select>
  72   </fieldset>
  73   <fieldset>
  74     <legend>Please confirm your age</legend> <input name="age" class="element text small" type="text" maxlength="255" value="">
  75   </fieldset>
  76   <fieldset>
  77     <legend>Comment or Special Instructions (if any)</legend>
  78     <textarea id="element_6" name="comments" class="element textarea small"></textarea>
  79   </fieldset><input type="hidden" name="paymentForm" value="259215"> <input id="placeorder" class="button_text" type="submit" name="submit" value="Place Order">
  80 </form>