?  search:
summary | log | graphiclog1 | graphiclog2 | commit | commitdiff | tree | refs | edit | fork
blame | history | raw | HEAD
Merge Chromium + Blink git repositories
[chromium-blink-merge.git] / chrome / test / data / autofill / heuristics / input / 16_crbug_87517.html
blobe33cbe3bc282aa0f4a05f3a844b657fd11b9909b
1 <!-- https://www.givedirect.org/give/givefrm.asp?CID=1721 -->
2 <table align="center" id="btable" width="810">
3 <tr>
4 <td valign="top" align="center" id="btable">
5 <h1>
6 MATHCOUNTS Foundation
7 </h1>
8 <h2>
9 Online Donation Form
10 </h2>
11 </td>
12 </tr>
13 <tr>
14 <td></td>
15 </tr>
16 <tr>
17 <td>
18 <form name="donation" method="post" id="donation">
19 <!--begin the form-->
20 <input type="hidden" name="IsSubmitted" value="Yes"> <input type="hidden" name="BaseURL" value=""> <span>
21 <textarea name="f1" id="f1" value="" rows="2" cols="3">
22 </textarea></span>
23 <table border="0">
24 <tr>
25 <td width="310">
26 <table>
27 <tr>
28 <td width="20">
29 <img src="#">
30 </td>
31 <td valign="middle" width="330">
32 <div>
33 Contact Information
34 </div>
35 </td>
36 </tr>
37 </table>
38 <div>
39 <div>
40 Name <span>*</span><br>
41 <input name="dnrfirst" value="" type="text" size="15" maxlength="50" tabindex="1">&nbsp;<input name="dnrlast" value="" type="text" size="15" maxlength="50" tabindex="2"><br>
42 Company<br>
43 <input name="company" value="" type="text" size="36" maxlength="100" tabindex="3"><br>
44 Address 1 <span>*</span><br>
45 <input name="dadd1" id="dadd1" value="" type="text" size="36" maxlength="155" tabindex="4" autocomplete="off"><br>
46 Address 2<br>
47 <input name="dadd2" id="dadd2" type="text" value="" size="36" maxlength="155" tabindex="5"><br>
48 City / State / Zip <span>*</span><br>
49 <input name="dcity" id="dcity" value="" type="text" size="12" maxlength="60" tabindex="6"> &nbsp; <select name="dstate" id="dstate" tabindex="6">
50 <option id="USA-AL" value="AL">
51 AL
52 </option>
53 <option id="USA-AK" value="AK">
54 AK
55 </option>
56 <option id="USA-AZ" value="AZ">
57 AZ
58 </option>
59 <option id="USA-AR" value="AR">
60 AR
61 </option>
62 <option id="USA-CA" value="CA">
63 CA
64 </option>
65 <option id="USA-CO" value="CO">
66 CO
67 </option>
68 <option id="USA-CT" value="CT">
69 CT
70 </option>
71 <option id="USA-DE" value="DE">
72 DE
73 </option>
74 <option id="USA-DC" value="DC">
75 DC
76 </option>
77 <option id="USA-FL" value="FL">
78 FL
79 </option>
80 <option id="USA-GA" value="GA">
81 GA
82 </option>
83 <option id="USA-GU" value="GU">
84 GU
85 </option>
86 <option id="USA-HI" value="HI">
87 HI
88 </option>
89 <option id="USA-ID" value="ID">
90 ID
91 </option>
92 <option id="USA-IL" value="IL">
93 IL
94 </option>
95 <option id="USA-IN" value="IN">
96 IN
97 </option>
98 <option id="USA-IA" value="IA">
99 IA
100 </option>
101 <option id="USA-KS" value="KS">
102 KS
103 </option>
104 <option id="USA-KY" value="KY">
105 KY
106 </option>
107 <option id="USA-LA" value="LA">
108 LA
109 </option>
110 <option id="USA-ME" value="ME">
111 ME
112 </option>
113 <option id="USA-MD" value="MD">
114 MD
115 </option>
116 <option id="USA-MA" value="MA">
117 MA
118 </option>
119 <option id="USA-MI" value="MI">
120 MI
121 </option>
122 <option id="USA-MN" value="MN">
123 MN
124 </option>
125 <option id="USA-MS" value="MS">
126 MS
127 </option>
128 <option id="USA-MO" value="MO">
129 MO
130 </option>
131 <option id="USA-MT" value="MT">
132 MT
133 </option>
134 <option id="USA-NE" value="NE">
135 NE
136 </option>
137 <option id="USA-NV" value="NV">
138 NV
139 </option>
140 <option id="USA-NH" value="NH">
141 NH
142 </option>
143 <option id="USA-NJ" value="NJ">
144 NJ
145 </option>
146 <option id="USA-NM" value="NM">
147 NM
148 </option>
149 <option id="USA-NY" value="NY">
150 NY
151 </option>
152 <option id="USA-NC" value="NC">
153 NC
154 </option>
155 <option id="USA-ND" value="ND">
156 ND
157 </option>
158 <option id="USA-OH" value="OH">
159 OH
160 </option>
161 <option id="USA-OK" value="OK">
162 OK
163 </option>
164 <option id="USA-OR" value="OR">
165 OR
166 </option>
167 <option id="USA-PA" value="PA">
168 PA
169 </option>
170 <option id="USA-PR" value="PR">
171 PR
172 </option>
173 <option id="USA-RI" value="RI">
174 RI
175 </option>
176 <option id="USA-SC" value="SC">
177 SC
178 </option>
179 <option id="USA-SD" value="SD">
180 SD
181 </option>
182 <option id="USA-TN" value="TN">
183 TN
184 </option>
185 <option id="USA-TX" value="TX">
186 TX
187 </option>
188 <option id="USA-UT" value="UT">
189 UT
190 </option>
191 <option id="USA-VT" value="VT">
192 VT
193 </option>
194 <option id="USA-VA" value="VA">
195 VA
196 </option>
197 <option id="USA-VI" value="VI">
198 VI
199 </option>
200 <option id="USA-WA" value="WA">
201 WA
202 </option>
203 <option id="USA-WV" value="WV">
204 WV
205 </option>
206 <option id="USA-WI" value="WI">
207 WI
208 </option>
209 <option id="USA-WY" value="WY">
210 WY
211 </option>
212 <option>
213 ----
214 </option>
215 <option id="CAN-AB" value="AB">
216 AB
217 </option>
218 <option id="CAN-BC" value="BC">
219 BC
220 </option>
221 <option id="CAN-MB" value="MB">
222 MB
223 </option>
224 <option id="CAN-NB" value="NB">
225 NB
226 </option>
227 <option id="CAN-NL" value="NL">
228 NL
229 </option>
230 <option id="CAN-NT" value="NT">
231 NT
232 </option>
233 <option id="CAN-NS" value="NS">
234 NS
235 </option>
236 <option id="CAN-NU" value="NU">
237 NU
238 </option>
239 <option id="CAN-PE" value="PE">
240 PE
241 </option>
242 <option id="CAN-SK" value="SK">
243 SK
244 </option>
245 <option id="CAN-ON" value="ON">
246 ON
247 </option>
248 <option id="CAN-QC" value="QC">
249 QC
250 </option>
251 <option id="CAN-YT" value="YT">
252 YT
253 </option>
254 <option>
255 ----
256 </option>
257 <option id="OS-AA" value="AA">
258 AA
259 </option>
260 <option id="OS-AE" value="AE">
261 AE
262 </option>
263 <option id="OS-AP" value="AP">
264 AP
265 </option>
266 </select> &nbsp; <input name="dzip" id="dzip" value="" type="text" size="8" maxlength="10" tabindex="7"><br>
267 Country<br>
268 <select name="CC_COUNTRY">
269 <option value="Albania">
270 Albania
271 </option>
272 <option value="Algeria">
273 Algeria
274 </option>
275 <option value="American Samoa">
276 American Samoa
277 </option>
278 <option value="Andorra">
279 Andorra
280 </option>
281 <option value="Anguilla">
282 Anguilla
283 </option>
284 <option value="Antigua">
285 Antigua
286 </option>
287 <option value="Argentina">
288 Argentina
289 </option>
290 <option value="Aruba">
291 Aruba
292 </option>
293 <option value="Australia">
294 Australia
295 </option>
296 <option value="Austria">
297 Austria
298 </option>
299 <option value="Azores">
300 Azores
301 </option>
302 <option value="Bahamas">
303 Bahamas
304 </option>
305 <option value="Bahrain">
306 Bahrain
307 </option>
308 <option value="Bangladesh">
309 Bangladesh
310 </option>
311 <option value="Barbados">
312 Barbados
313 </option>
314 <option value="Belgium">
315 Belgium
316 </option>
317 <option value="Belize">
318 Belize
319 </option>
320 <option value="Belarus">
321 Belarus
322 </option>
323 <option value="Benin">
324 Benin
325 </option>
326 <option value="Bermuda">
327 Bermuda
328 </option>
329 <option value="Bolivia">
330 Bolivia
331 </option>
332 <option value="Bonaire">
333 Bonaire
334 </option>
335 <option value="Botswana">
336 Botswana
337 </option>
338 <option value="Brazil">
339 Brazil
340 </option>
341 <option value="Brunei">
342 Brunei
343 </option>
344 <option value="Bulgaria">
345 Bulgaria
346 </option>
347 <option value="Burkina Faso">
348 Burkina Faso
349 </option>
350 <option value="Burundi">
351 Burundi
352 </option>
353 <option value="Cambodia">
354 Cambodia
355 </option>
356 <option value="Cameroon">
357 Cameroon
358 </option>
359 <option value="Canada">
360 Canada
361 </option>
362 <option value="Canary Islands">
363 Canary Islands
364 </option>
365 <option value="Cape Verde Islands">
366 Cape Verde Islands
367 </option>
368 <option value="Cayman Islands">
369 Cayman Islands
370 </option>
371 <option value="Channel Islands">
372 Channel Islands
373 </option>
374 <option value="Chile">
375 Chile
376 </option>
377 <option value="China">
378 China
379 </option>
380 <option value="Colombia">
381 Colombia
382 </option>
383 <option value="Congo">
384 Congo
385 </option>
386 <option value="Cook Islands">
387 Cook Islands
388 </option>
389 <option value="Costa Rica">
390 Costa Rica
391 </option>
392 <option value="Croatia">
393 Croatia
394 </option>
395 <option value="Curacao">
396 Curacao
397 </option>
398 <option value="Cyprus">
399 Cyprus
400 </option>
401 <option value="Czech Republic">
402 Czech Republic
403 </option>
404 <option value="Denmark">
405 Denmark
406 </option>
407 <option value="Djibouti">
408 Djibouti
409 </option>
410 <option value="Dominica">
411 Dominica
412 </option>
413 <option value="Dominican Republic">
414 Dominican Republic
415 </option>
416 <option value="Ecuador">
417 Ecuador
418 </option>
419 <option value="Egypt">
420 Egypt
421 </option>
422 <option value="El Salvador">
423 El Salvador
424 </option>
425 <option value="England">
426 England
427 </option>
428 <option value="Equitorial Guinea">
429 Equitorial Guinea
430 </option>
431 <option value="Eritrea">
432 Eritrea
433 </option>
434 <option value="Estonia">
435 Estonia
436 </option>
437 <option value="Ethiopia">
438 Ethiopia
439 </option>
440 <option value="Faeroe Islands">
441 Faeroe Islands
442 </option>
443 <option value="Fiji">
444 Fiji
445 </option>
446 <option value="Finland">
447 Finland
448 </option>
449 <option value="France">
450 France
451 </option>
452 <option value="French Guiana">
453 French Guiana
454 </option>
455 <option value="French Polynesia">
456 French Polynesia
457 </option>
458 <option value="Gabon">
459 Gabon
460 </option>
461 <option value="Gambia">
462 Gambia
463 </option>
464 <option value="Georgia">
465 Georgia
466 </option>
467 <option value="Germany">
468 Germany
469 </option>
470 <option value="Ghana">
471 Ghana
472 </option>
473 <option value="Gibraltar">
474 Gibraltar
475 </option>
476 <option value="Greece">
477 Greece
478 </option>
479 <option value="Greenland">
480 Greenland
481 </option>
482 <option value="Grenada">
483 Grenada
484 </option>
485 <option value="Guadeloupe">
486 Guadeloupe
487 </option>
488 <option value="Guam">
489 Guam
490 </option>
491 <option value="Guatemala">
492 Guatemala
493 </option>
494 <option value="Guinea">
495 Guinea
496 </option>
497 <option value="Guinea-Bissau">
498 Guinea-Bissau
499 </option>
500 <option value="Guyana">
501 Guyana
502 </option>
503 <option value="Haiti">
504 Haiti
505 </option>
506 <option value="Holland">
507 Holland
508 </option>
509 <option value="Honduras">
510 Honduras
511 </option>
512 <option value="Hong Kong">
513 Hong Kong
514 </option>
515 <option value="Hungary">
516 Hungary
517 </option>
518 <option value="Iceland">
519 Iceland
520 </option>
521 <option value="India">
522 India
523 </option>
524 <option value="Indonesia">
525 Indonesia
526 </option>
527 <option value="Ireland">
528 Ireland
529 </option>
530 <option value="Israel">
531 Israel
532 </option>
533 <option value="Italy">
534 Italy
535 </option>
536 <option value="Ivory Coast">
537 Ivory Coast
538 </option>
539 <option value="Jamaica">
540 Jamaica
541 </option>
542 <option value="Japan">
543 Japan
544 </option>
545 <option value="Jordan">
546 Jordan
547 </option>
548 <option value="Kazakhstan">
549 Kazakhstan
550 </option>
551 <option value="Kenya">
552 Kenya
553 </option>
554 <option value="Kiribati">
555 Kiribati
556 </option>
557 <option value="Kosrae">
558 Kosrae
559 </option>
560 <option value="Kuwait">
561 Kuwait
562 </option>
563 <option value="Kyrgyzstan">
564 Kyrgyzstan
565 </option>
566 <option value="Laos">
567 Laos
568 </option>
569 <option value="Latvia">
570 Latvia
571 </option>
572 <option value="Lebanon">
573 Lebanon
574 </option>
575 <option value="Lesotho">
576 Lesotho
577 </option>
578 <option value="Liberia">
579 Liberia
580 </option>
581 <option value="Liechtenstein">
582 Liechtenstein
583 </option>
584 <option value="Lithuania">
585 Lithuania
586 </option>
587 <option value="Luxembourg">
588 Luxembourg
589 </option>
590 <option value="Macau">
591 Macau
592 </option>
593 <option value="Macedonia">
594 Macedonia
595 </option>
596 <option value="Madagascar">
597 Madagascar
598 </option>
599 <option value="Madeira">
600 Madeira
601 </option>
602 <option value="Malawi">
603 Malawi
604 </option>
605 <option value="Malaysia">
606 Malaysia
607 </option>
608 <option value="Maldives">
609 Maldives
610 </option>
611 <option value="Mali">
612 Mali
613 </option>
614 <option value="Malta">
615 Malta
616 </option>
617 <option value="Marshall Islands">
618 Marshall Islands
619 </option>
620 <option value="Martinique">
621 Martinique
622 </option>
623 <option value="Mauritania">
624 Mauritania
625 </option>
626 <option value="Mauritius">
627 Mauritius
628 </option>
629 <option value="Mexico">
630 Mexico
631 </option>
632 <option value="Moldova">
633 Moldova
634 </option>
635 <option value="Monaco">
636 Monaco
637 </option>
638 <option value="Montserrat">
639 Montserrat
640 </option>
641 <option value="Morocco">
642 Morocco
643 </option>
644 <option value="Mozambique">
645 Mozambique
646 </option>
647 <option value="Myanmar">
648 Myanmar
649 </option>
650 <option value="Namibia">
651 Namibia
652 </option>
653 <option value="Nepal">
654 Nepal
655 </option>
656 <option value="Netherlands">
657 Netherlands
658 </option>
659 <option value="New Caledonia">
660 New Caledonia
661 </option>
662 <option value="New Zealand">
663 New Zealand
664 </option>
665 <option value="Nicaragua">
666 Nicaragua
667 </option>
668 <option value="Niger">
669 Niger
670 </option>
671 <option value="Nigeria">
672 Nigeria
673 </option>
674 <option value="Norfolk Island">
675 Norfolk Island
676 </option>
677 <option value="Northern Ireland">
678 Northern Ireland
679 </option>
680 <option value="Norway">
681 Norway
682 </option>
683 <option value="Oman">
684 Oman
685 </option>
686 <option value="Pakistan">
687 Pakistan
688 </option>
689 <option value="Palau">
690 Palau
691 </option>
692 <option value="Panama">
693 Panama
694 </option>
695 <option value="Papua New Guinea">
696 Papua New Guinea
697 </option>
698 <option value="Paraguay">
699 Paraguay
700 </option>
701 <option value="Peru">
702 Peru
703 </option>
704 <option value="Philippines">
705 Philippines
706 </option>
707 <option value="Poland">
708 Poland
709 </option>
710 <option value="Ponape">
711 Ponape
712 </option>
713 <option value="Portugal">
714 Portugal
715 </option>
716 <option value="Puerto Rico">
717 Puerto Rico
718 </option>
719 <option value="Qatar">
720 Qatar
721 </option>
722 <option value="Reunion">
723 Reunion
724 </option>
725 <option value="Romania">
726 Romania
727 </option>
728 <option value="Rota">
729 Rota
730 </option>
731 <option value="Russia">
732 Russia
733 </option>
734 <option value="Rwanda">
735 Rwanda
736 </option>
737 <option value="Saba">
738 Saba
739 </option>
740 <option value="Saipan">
741 Saipan
742 </option>
743 <option value="Saudi Arabia">
744 Saudi Arabia
745 </option>
746 <option value="Scotland">
747 Scotland
748 </option>
749 <option value="Senegal">
750 Senegal
751 </option>
752 <option value="Seychelles">
753 Seychelles
754 </option>
755 <option value="Sierra Leone">
756 Sierra Leone
757 </option>
758 <option value="Singapore">
759 Singapore
760 </option>
761 <option value="Slovakia">
762 Slovakia
763 </option>
764 <option value="Slovenia">
765 Slovenia
766 </option>
767 <option value="Solomon Islands">
768 Solomon Islands
769 </option>
770 <option value="South Africa">
771 South Africa
772 </option>
773 <option value="South Korea">
774 South Korea
775 </option>
776 <option value="Spain">
777 Spain
778 </option>
779 <option value="Sri Lanka">
780 Sri Lanka
781 </option>
782 <option value="St. Barthelemy">
783 St. Barthelemy
784 </option>
785 <option value="St. Christopher">
786 St. Christopher
787 </option>
788 <option value="St. Croix">
789 St. Croix
790 </option>
791 <option value="St. Eustatius">
792 St. Eustatius
793 </option>
794 <option value="St. John">
795 St. John
796 </option>
797 <option value="St. Lucia">
798 St. Lucia
799 </option>
800 <option value="St. Maarten">
801 St. Maarten
802 </option>
803 <option value="St. Martin">
804 St. Martin
805 </option>
806 <option value="St. Thomas">
807 St. Thomas
808 </option>
809 <option value="Sudan">
810 Sudan
811 </option>
812 <option value="Suriname">
813 Suriname
814 </option>
815 <option value="Swaziland">
816 Swaziland
817 </option>
818 <option value="Sweden">
819 Sweden
820 </option>
821 <option value="Switzerland">
822 Switzerland
823 </option>
824 <option value="Syria">
825 Syria
826 </option>
827 <option value="Tahiti">
828 Tahiti
829 </option>
830 <option value="Taiwan">
831 Taiwan
832 </option>
833 <option value="Tajikistan">
834 Tajikistan
835 </option>
836 <option value="Tanzania">
837 Tanzania
838 </option>
839 <option value="Thailand">
840 Thailand
841 </option>
842 <option value="Tinian">
843 Tinian
844 </option>
845 <option value="Togo">
846 Togo
847 </option>
848 <option value="Tonga">
849 Tonga
850 </option>
851 <option value="Tortola">
852 Tortola
853 </option>
854 <option value="Trinidad and Tobago">
855 Trinidad and Tobago
856 </option>
857 <option value="Truk">
858 Truk
859 </option>
860 <option value="Tunisia">
861 Tunisia
862 </option>
863 <option value="Turkey">
864 Turkey
865 </option>
866 <option value="Tuvalu">
867 Tuvalu
868 </option>
869 <option value="Uganda">
870 Uganda
871 </option>
872 <option value="Ukraine">
873 Ukraine
874 </option>
875 <option value="Union Island">
876 Union Island
877 </option>
878 <option value="United Arab Emirates">
879 United Arab Emirates
880 </option>
881 <option value="United Kingdom">
882 United Kingdom
883 </option>
884 <option value="United States" selected>
885 United States
886 </option>
887 <option value="Uruguay">
888 Uruguay
889 </option>
890 <option value="US Virgin Islands">
891 US Virgin Islands
892 </option>
893 <option value="Uzbekistan">
894 Uzbekistan
895 </option>
896 <option value="Vanuatu">
897 Vanuatu
898 </option>
899 <option value="Venezuela">
900 Venezuela
901 </option>
902 <option value="Vietnam">
903 Vietnam
904 </option>
905 <option value="Virgin Gorda">
906 Virgin Gorda
907 </option>
908 <option value="Wake Island">
909 Wake Island
910 </option>
911 <option value="Wales">
912 Wales
913 </option>
914 <option value="Western Samoa">
915 Western Samoa
916 </option>
917 <option value="Yap">
918 Yap
919 </option>
920 <option value="Yemen">
921 Yemen
922 </option>
923 <option value="Zaire">
924 Zaire
925 </option>
926 <option value="Zambia">
927 Zambia
928 </option>
929 <option value="Zimbabwe">
930 Zimbabwe
931 </option>
932 </select><br>
933 Telephone<br>
934 <input name="dphone" value="" type="text" size="36" maxlength="20" tabindex="8"><br>
935 Email <span>*</span><br>
936 <input name="demail" value="" type="text" size="36" maxlength="155" tabindex="9"><br>
937 <br>
938 </div>
939 </div>
940 </td>
941 <td>
942 <div>
943 <table border="0">
944 <tr>
945 <td>
946 <img src="#" alt="Number 2">
947 </td>
948 <td valign="middle" width="350">
949 <div>
950 &nbsp;Donation Information
951 </div>
952 </td>
953 </tr>
954 </table>
955 <div>
956 <b>Gift amount in USD <span>($10 minimum)</span><br>
957 $<input name="amt" id="amt" type="text" value="" size="5" maxlength="25" tabindex="10">.00</b>
958 <p>
959 <input type="checkbox" name="tributeSelect" tabindex="11" value="on"> My donation is In Honor or In Memory of someone special
960 </p>
961 <p>
962 <!--<b>Donation Preference</b><br>-->
963 <input name="DonationType" type="radio" value="OneTime" checked tabindex="12">This is a one time donation<br>
964 <input name="DonationType" type="radio" value="Recurs" tabindex="13">I would like to make this a recurring donation deducted <select name="ccrecurring" tabindex="14">
965 <option value="Monthly">
966 Monthly
967 </option>
968 <option value="Quarterly">
969 Quarterly
970 </option>
971 <option value="Annually">
972 Annually
973 </option>
974 </select>
975 </p>
976 <p>
977 <b>Comments</b><br>
978 <span>( You may enter up to 500 characters. )&nbsp;&nbsp;&nbsp;<input value="500" name="remLen" size="3" maxlength="3" readonly="readonly"> characters left</span><br>
979 <textarea name="Comments" rows="3" cols="45" wrap="physical" onkeydown="textCounter(this.form.Comments,this.form.remLen,500);" onkeyup="textCounter(this.form.Comments,this.form.remLen,500);" tabindex="17">
980 </textarea>
981 </p>
982 </div>
983 </div>
984 </td>
985 </tr>
986 <tr>
987 <td colspan="2">
988 <div id="div_tribute" style='display: none;'><br>
989 <table border="0">
990 <tr>
991 <td width="20">
992 <img src="#">
993 </td>
994 <td valign="middle" width="330">
995 <div>
996 Tribute Information:
997 </div>
998 </td>
999 </tr>
1000 </table>
1001 <div>
1002 <table>
1003 <tr>
1004 <td>
1005 <table>
1006 <tr>
1007 <td></td>
1008 <td>
1009 <input type="radio" name="tribute" value="IHO" tabindex="18">In Honor Of &nbsp;&nbsp;&nbsp; <input type="radio" name="tribute" value="IMO" tabindex="19">In Memory Of
1010 </td>
1011 </tr>
1012 <tr>
1013 <td>
1014 Name:
1015 </td>
1016 <td>
1017 <input type="text" name="Tribute_Name" maxlength="100" size="35" value="" tabindex="20">
1018 </td>
1019 </tr>
1020 <tr>
1021 <td>
1022 Occasion:
1023 </td>
1024 <td>
1025 <input type="text" name="Tribute_occasion" maxlength="100" size="35" value="" tabindex="21">
1026 </td>
1027 </tr>
1028 <tr>
1029 <td colspan="2" align="left">
1030 <input type="checkbox" name="Tribute_Disclosure" value="on" tabindex="22">I wish to remain anonymous<br>
1031 <input type="checkbox" name="Tribute_Notification" value="on" tabindex="23">Please send a notification of my gift to the following address:
1032 </td>
1033 </tr>
1034 </table>
1035 </td>
1036 <td>
1037 <div id="div_notify" style='display: none;'>
1038 <div>
1039 <table>
1040 <tr>
1041 <td colspan="2" align="right">
1042 <input type="radio" name="Tribute_IncludeAmount" tabindex="24" value="1">Include the amount &nbsp;&nbsp; <input type="radio" name="Tribute_IncludeAmount" checked tabindex="25" value="0">Do not include the amount
1043 </td>
1044 </tr>
1045 <tr>
1046 <td>
1047 Name:
1048 </td>
1049 <td>
1050 <input type="text" name="Tribute_NotifyName" maxlength="100" size="40" value="" tabindex="26">
1051 </td>
1052 </tr>
1053 <tr>
1054 <td>
1055 Email:
1056 </td>
1057 <td>
1058 <input type="text" name="Tribute_Email" maxlength="50" size="40" value="" tabindex="27">
1059 </td>
1060 </tr>
1061 <tr>
1062 <td>
1063 Street:
1064 </td>
1065 <td>
1066 <input type="text" name="Tribute_NotifyAddr" maxlength="200" size="40" value="" tabindex="28">
1067 </td>
1068 </tr>
1069 <tr>
1070 <td>
1071 City / St. / Zip:
1072 </td>
1073 <td>
1074 <input type="text" name="Tribute_NotifyCity" maxlength="60" size="15" value="" tabindex="29"> &nbsp; <input type="text" name="Tribute_NotifyState" maxlength="10" size="2" value="" tabindex="30"> &nbsp; <input type="text" name="Tribute_NotifyZip" maxlength="10" size="10" value="" tabindex="31">
1075 </td>
1076 </tr>
1077 </table>
1078 </div>
1079 </td>
1080 </tr>
1081 </table>
1082 </div><!-- End Hide Notify Div -->
1083 <!-- End TributeBox Div --><!-- End Hide Tribute Div -->
1084 </td>
1085 </tr>
1086 <tr>
1087 <td colspan="2">
1088 <!-- ///PAYMENT BOX -->
1089 <br>
1090 <table border="0">
1091 <tr>
1092 <td width="20">
1093 <div id="div_payment">
1094 <img src='images/icons/red4.png'>
1095 </div>
1096 <div id="div_paymentmain">
1097 <img src='images/icons/red3.png'>
1098 </div>
1099 </td>
1100 <td valign="middle" width="330">
1101 <div>
1102 Payment Information:
1103 </div>
1104 </td>
1105 </tr>
1106 </table>
1107 <div>
1108 <table>
1109 <tr>
1110 <td width="10"></td>
1111 <td>
1112 <p>
1113 <b>Credit Card Information</b><br>
1114 <img src="#"><br>
1115 <br>
1116 Credit Card Type <span>*</span><br>
1117 <select name="cctype" tabindex="32">
1118 <option value="Visa">
1119 Visa
1120 </option>
1121 <option value="MasterCard">
1122 MasterCard
1123 </option>
1124 <option value="AmericanExpress">
1125 American Express
1126 </option>
1127 </select><br>
1128 Credit Card Number <span>*</span><br>
1129 <input name="ccard" type="text" value="" size="25" maxlength="25" tabindex="32" autocomplete="off"><br>
1130 CSC Number <span>* <a href="#">What Is This?</a></span><br>
1131 <input tabindex="33" name="csc" type="text" value="" size="25" maxlength="4" autocomplete="off"><br>
1132 Expiration Date <span>*</span><br>
1133 Month <select name="ExpMon" tabindex="34">
1134 <option value="1">
1135 1
1136 </option>
1137 <option value="2">
1138 2
1139 </option>
1140 <option value="3">
1141 3
1142 </option>
1143 <option value="4">
1144 4
1145 </option>
1146 <option value="5">
1147 5
1148 </option>
1149 <option value="6">
1150 6
1151 </option>
1152 <option value="7">
1153 7
1154 </option>
1155 <option value="8">
1156 8
1157 </option>
1158 <option value="9">
1159 9
1160 </option>
1161 <option value="10">
1162 10
1163 </option>
1164 <option value="11">
1165 11
1166 </option>
1167 <option value="12">
1168 12
1169 </option>
1170 </select> Year <select name="ExpYear" size="1" tabindex="35">
1171 <option value="11">
1172 2011
1173 </option>
1174 <option value="12">
1175 2012
1176 </option>
1177 <option value="13">
1178 2013
1179 </option>
1180 <option value="14">
1181 2014
1182 </option>
1183 <option value="15">
1184 2015
1185 </option>
1186 <option value="16">
1187 2016
1188 </option>
1189 <option value="17">
1190 2017
1191 </option>
1192 <option value="18">
1193 2018
1194 </option>
1195 <option value="19">
1196 2019
1197 </option>
1198 </select><br>
1199 </p>
1200 </td>
1201 <td width="150"></td>
1202 <td>
1203 <p>
1204 <b>Billing Address</b> - <input type="checkbox" name="SameAddress" value="checkbox" tabindex="36">Same As Contact Address<br>
1205 <br>
1206 Address 1 <span>*</span><br>
1207 <input name="CC_Addr" id="CC_Addr" value="" type="text" size="36" maxlength="155" tabindex="37"><br>
1208 Address 2<br>
1209 <input name="CC_Addr2" id="CC_Addr2" type="text" value="" size="36" maxlength="155" tabindex="38"><br>
1210 City / State / Zip <span>*</span><br>
1211 <input name="CC_City" id="CC_City" value="" type="text" size="12" maxlength="60" tabindex="39"> &nbsp; <input name="CC_State" id="CC_State" value="" type="text" size="2" maxlength="10" tabindex="40"> &nbsp; <input name="CC_Zip" id="CC_Zip" value="" type="text" size="10" maxlength="10" tabindex="41">
1212 </p>
1213 <p>
1214 <b>Thank you for your support!</b>
1215 </p>
1216 <p>
1217 <input type="image" src="#" name="Action" value="Submit" tabindex="42">
1218 </p>
1219 </td>
1220 </tr>
1221 </table>
1222 </div><!-- End Payment Box div -->
1223 </td>
1224 </tr>
1225 </table>
1226 </form>
1227 </td>
1228 </tr>
1229 </table>