chrome/test/data/autofill/heuristics/input/bug_469012.html

   1 <form action="/ticket/addcard.do" method="post" id="payment_new">
   2   <div class="dmethod">
   3     <input type="hidden" name="newcard" value="1">
   4     <input type="hidden" name="dest" value="/tmloggedin.do">
   5
   6     <div class="center"><img src="/styles/tmus/amex_parity_mini.gif" alt="creditcards">
   7
   8
   9       <img src="/styles/tmus/visa_parity_mini.gif" alt="creditcards">
  10       <img src="/styles/tmus/mc_parity_mini.gif" alt="creditcards">
  11       <img src="/styles/tmus/diners_parity_mini.gif" alt="creditcards">
  12       <img src="/styles/tmus/discover_network_parity_mini.gif" alt="creditcards">
  13     </div>
  14
  15     <label>Card Issuer</label>
  16     <select name="cardissuer">
  17       <option value="">Select Card Type</option>
  18       <option value="AMEX">American Express</option>
  19       <option value="VISA">VISA</option>
  20       <option value="MC">MasterCard</option>
  21       <option value="DISCOVER">Discover Network</option>
  22       <option value="DINERS">Diners Club</option>
  23     </select><br>
  24     <label>Your cardnumber</label>
  25     <input name="cardnumber" type="text" pattern="[0-9]*" placeholder="Your 16 digit number">
  26     <fieldset class="expiration">
  27       <label><strong id="new_credit_card_expire_heading">Expiration Date</strong>
  28       </label>
  29       <select id="expire_month" name="expire_month">
  30         <option value="">Month</option>
  31         <option value="1">1</option>
  32         <option value="2">2</option>
  33         <option value="3">3</option>
  34         <option value="4">4</option>
  35         <option value="5">5</option>
  36         <option value="6">6</option>
  37         <option value="7">7</option>
  38         <option value="8">8</option>
  39         <option value="9">9</option>
  40         <option value="10">10</option>
  41         <option value="11">11</option>
  42         <option value="12">12</option>
  43       </select>
  44
  45       <select id="expire_year" name="expire_year">
  46         <option value="">Year</option>
  47         <option value="2015">2015</option>
  48         <option value="2016">2016</option>
  49         <option value="2017">2017</option>
  50         <option value="2018">2018</option>
  51         <option value="2019">2019</option>
  52         <option value="2020">2020</option>
  53         <option value="2021">2021</option>
  54         <option value="2022">2022</option>
  55         <option value="2023">2023</option>
  56         <option value="2024">2024</option>
  57         <option value="2025">2025</option>
  58         <option value="2026">2026</option>
  59         <option value="2027">2027</option>
  60         <option value="2028">2028</option>
  61         <option value="2029">2029</option>
  62       </select>
  63
  64     </fieldset>
  65   </div>
  66
  67   <div class="dmethod">
  68     <span class="info" title="= Fields marked with an * are required">* = Required Text</span>
  69
  70     <div class="smalltext">Enter the credit card billing address and name exactly as it appears on your credit card statement.
  71     </div>
  72
  73     <div class="billInfo">
  74       <fieldset>
  75
  76         <div class="formline">
  77           <label for="first_name" id="address_form_label_first_name">First Name <span class="requiredText">*</span> </label>
  78           <input type="text" name="firstname" id="first_name" size="35" maxlength="80">
  79
  80         </div>
  81         <div class="formline">
  82           <label for="last_name" id="address_form_label_last_name">Last Name <span class="requiredText">*</span> </label>
  83           <input type="text" name="lastname" id="last_name" size="35" maxlength="80">
  84         </div>
  85         <div class="formline">
  86           <label for="address1">Address
  87             <span class="requiredText">*</span> </label>
  88           <input type="text" size="35" maxlength="30" name="address1" id="address1"></div>
  89         <div class="formline"> <span id="unit_title_span"><label for="unit">Unit #</label></span>
  90
  91           <span id="unit_input_span"><input type="text" size="10" name="unit" id="unit"></span> <span id="unit_optional_span" class="txt11">(Optional)</span>
  92         </div>
  93         <div class="formline">
  94           <label for="address2"><span id="address2_title_span">Address Line 2</span></label>
  95           <input type="text" size="35" name="address2" id="address2">
  96         </div>
  97         <div class="formline">
  98           <label for="city"><span id="city_title_span">City                    </span>&nbsp;<span class="requiredText">*</span> </label>
  99           <input type="text" name="city" id="city" size="35">
 100           <span class="info">Military Address? Enter APO or FPO.</span>
 101         </div>
 102
 103         <div class="formline">
 104           <label for="state_id"><span id="state_title_span">State                    </span> <span class="requiredText">*</span> </label>
 105           <span id="state_input_span">
 106             <select name="state" id="state_id">
 107               <option value="">-- Select State
 108               --
 109               </option>
 110               <option value="AL">Alabama</option>
 111               <option value="AK">Alaska</option>
 112               <option value="AS">American Samoa</option>
 113               <option value="AZ">Arizona</option>
 114               <option value="AR">Arkansas</option>
 115               <option value="AA">Armed Forces Americas</option>
 116               <option value="AE">Armed Forces Other</option>
 117               <option value="AP">Armed Forces Pacific</option>
 118               <option value="CA">California</option>
 119               <option value="CO">Colorado</option>
 120               <option value="CT">Connecticut</option>
 121               <option value="DE">Delaware</option>
 122               <option value="DC">District Of Columbia</option>
 123               <option value="FM">Federated States Of Micronesia</option>
 124               <option value="FL">Florida</option>
 125               <option value="GA">Georgia</option>
 126               <option value="GU">Guam</option>
 127               <option value="HI">Hawaii</option>
 128               <option value="ID">Idaho</option>
 129               <option value="IL">Illinois</option>
 130               <option value="IN">Indiana</option>
 131               <option value="IA">Iowa</option>
 132               <option value="KS">Kansas</option>
 133               <option value="KY">Kentucky</option>
 134               <option value="LA">Louisiana</option>
 135               <option value="ME">Maine</option>
 136               <option value="MH">Marshall Islands</option>
 137               <option value="MD">Maryland</option>
 138               <option value="MA">Massachusetts</option>
 139               <option value="MI">Michigan</option>
 140               <option value="MN">Minnesota</option>
 141               <option value="MS">Mississippi</option>
 142               <option value="MO">Missouri</option>
 143               <option value="MT">Montana</option>
 144               <option value="NE">Nebraska</option>
 145               <option value="NV">Nevada</option>
 146               <option value="NH">New Hampshire</option>
 147               <option value="NJ">New Jersey</option>
 148               <option value="NM">New Mexico</option>
 149               <option value="NY">New York</option>
 150               <option value="NC">North Carolina</option>
 151               <option value="ND">North Dakota</option>
 152               <option value="MP">Northern Mariana Islands</option>
 153               <option value="OH">Ohio</option>
 154               <option value="OK">Oklahoma</option>
 155               <option value="OR">Oregon</option>
 156               <option value="PW">Palau</option>
 157               <option value="PA">Pennsylvania</option>
 158               <option value="PR">Puerto Rico</option>
 159               <option value="RI">Rhode Island</option>
 160               <option value="SC">South Carolina</option>
 161               <option value="SD">South Dakota</option>
 162               <option value="TN">Tennessee</option>
 163               <option value="TX">Texas</option>
 164               <option value="UT">Utah</option>
 165               <option value="VT">Vermont</option>
 166               <option value="VI">Virgin Islands</option>
 167               <option value="VA">Virginia</option>
 168               <option value="WA">Washington</option>
 169               <option value="WV">West Virginia</option>
 170               <option value="WI">Wisconsin</option>
 171               <option value="WY">Wyoming</option>
 172         </div>
 173         <div class="formline">
 174           <label for="postal_code"><span id="zip_title_span">ZIP Code</span><span class="requiredText">*</span>
 175           </label>
 176
 177           <input type="text" name="zip" id="postal_code" size="35" autocapitalize="off" autocomplete="off">
 178         </div>
 179         <div class="formline">
 180           <label for="country">Country
 181             <span class="requiredText">*</span>
 182           </label>
 183           <select name="country" id="countrylist">
 184             <option value="ad">Andorra</option>
 185             <option value="ae">United Arab Emirates</option>
 186             <option value="af">Afghanistan</option>
 187             <option value="ag">Antigua and Barbuda</option>
 188             <option value="ai">Anguilla</option>
 189             <option value="al">Albania</option>
 190             <option value="am">Armenia</option>
 191             <option value="an">Netherlands Antilles</option>
 192             <option value="ao">Angola</option>
 193             <option value="ap">Asia/Pacific Region</option>
 194             <option value="aq">Antarctica</option>
 195             <option value="ar">Argentina</option>
 196             <option value="as">American Samoa</option>
 197             <option value="at">Austria</option>
 198             <option value="au">Australia</option>
 199
 200             <option value="aw">Aruba</option>
 201             <option value="ax">Aland Islands</option>
 202             <option value="az">Azerbaijan</option>
 203             <option value="ba">Bosnia and Herzegovina</option>
 204             <option value="bb">Barbados</option>
 205             <option value="bd">Bangladesh</option>
 206             <option value="be">Belgium</option>
 207             <option value="bf">Burkina Faso</option>
 208             <option value="bg">Bulgaria</option>
 209             <option value="bh">Bahrain</option>
 210             <option value="bi">Burundi</option>
 211             <option value="bj">Benin</option>
 212             <option value="bm">Bermuda</option>
 213             <option value="bn">Brunei Darussalam</option>
 214             <option value="bo">Bolivia</option>
 215             <option value="br">Brazil</option>
 216             <option value="bs">Bahamas</option>
 217             <option value="bt">Bhutan</option>
 218             <option value="bv">Bouvet Island</option>
 219             <option value="bw">Botswana</option>
 220             <option value="by">Belarus</option>
 221             <option value="bz">Belize</option>
 222             <option value="ca">Canada</option>
 223             <option value="cc">Cocos (Keeling) Islands</option>
 224             <option value="cd">Congo The Democratic Republic of the</option>
 225             <option value="cf">Central African Republic</option>
 226             <option value="cg">Congo</option>
 227             <option value="ch">Switzerland</option>
 228             <option value="ci">Cote d'Ivoire</option>
 229             <option value="ck">Cook Islands</option>
 230             <option value="cl">Chile</option>
 231             <option value="cm">Cameroon</option>
 232             <option value="cn">China</option>
 233             <option value="co">Colombia</option>
 234             <option value="cr">Costa Rica</option>
 235             <option value="cu">Cuba</option>
 236             <option value="cv">Cape Verde</option>
 237             <option value="cx">Christmas Island</option>
 238             <option value="cy">Cyprus</option>
 239             <option value="cz">Czech Republic</option>
 240             <option value="de">Germany</option>
 241             <option value="dj">Djibouti</option>
 242             <option value="dk">Denmark</option>
 243             <option value="dm">Dominica</option>
 244             <option value="do">Dominican Republic</option>
 245             <option value="dz">Algeria</option>
 246             <option value="ec">Ecuador</option>
 247             <option value="ee">Estonia</option>
 248             <option value="eg">Egypt</option>
 249             <option value="eh">Western Sahara</option>
 250             <option value="er">Eritrea</option>
 251             <option value="es">Spain</option>
 252             <option value="et">Ethiopia</option>
 253             <option value="eu">Europe</option>
 254             <option value="fi">Finland</option>
 255             <option value="fj">Fiji</option>
 256             <option value="fk">Falkland Islands (Malvinas)</option>
 257             <option value="fm">Micronesia Federated States of</option>
 258             <option value="fo">Faroe Islands</option>
 259             <option value="fr">France</option>
 260             <option value="ga">Gabon</option>
 261             <option value="gb">United Kingdom</option>
 262             <option value="gd">Grenada</option>
 263             <option value="ge">Georgia</option>
 264             <option value="gf">French Guiana</option>
 265             <option value="gg">Guernsey</option>
 266             <option value="gh">Ghana</option>
 267             <option value="gi">Gibraltar</option>
 268             <option value="gl">Greenland</option>
 269             <option value="gm">Gambia</option>
 270             <option value="gn">Guinea</option>
 271             <option value="gp">Guadeloupe</option>
 272             <option value="gq">Equatorial Guinea</option>
 273             <option value="gr">Greece</option>
 274             <option value="gs">South Georgia and the South Sandwich Islands</option>
 275             <option value="gt">Guatemala</option>
 276             <option value="gu">Guam</option>
 277             <option value="gw">Guinea-Bissau</option>
 278             <option value="gy">Guyana</option>
 279             <option value="hk">Hong Kong</option>
 280             <option value="hm">Heard Island and McDonald Islands</option>
 281             <option value="hn">Honduras</option>
 282             <option value="hr">Croatia</option>
 283             <option value="ht">Haiti</option>
 284             <option value="hu">Hungary</option>
 285             <option value="id">Indonesia</option>
 286             <option value="ie">Ireland</option>
 287             <option value="il">Israel</option>
 288             <option value="im">Isle of Man</option>
 289             <option value="in">India</option>
 290             <option value="io">British Indian Ocean Territory</option>
 291             <option value="iq">Iraq</option>
 292             <option value="ir">Iran Islamic Republic of</option>
 293             <option value="is">Iceland</option>
 294             <option value="it">Italy</option>
 295             <option value="je">Jersey</option>
 296             <option value="jm">Jamaica</option>
 297             <option value="jo">Jordan</option>
 298             <option value="jp">Japan</option>
 299             <option value="ke">Kenya</option>
 300             <option value="kg">Kyrgyzstan</option>
 301             <option value="kh">Cambodia</option>
 302             <option value="ki">Kiribati</option>
 303             <option value="km">Comoros</option>
 304             <option value="kn">Saint Kitts and Nevis</option>
 305             <option value="kp">Korea Democratic People's Republic of</option>
 306             <option value="kr">Korea Republic of</option>
 307             <option value="kw">Kuwait</option>
 308             <option value="ky">Cayman Islands</option>
 309             <option value="kz">Kazakhstan</option>
 310             <option value="la">Lao People's Democratic Republic</option>
 311             <option value="lb">Lebanon</option>
 312             <option value="lc">Saint Lucia</option>
 313             <option value="li">Liechtenstein</option>
 314             <option value="lk">Sri Lanka</option>
 315             <option value="lr">Liberia</option>
 316             <option value="ls">Lesotho</option>
 317             <option value="lt">Lithuania</option>
 318             <option value="lu">Luxembourg</option>
 319             <option value="lv">Latvia</option>
 320             <option value="ly">Libyan Arab Jamahiriya</option>
 321             <option value="ma">Morocco</option>
 322             <option value="mc">Monaco</option>
 323             <option value="md">Moldova Republic of</option>
 324             <option value="me">Montenegro</option>
 325             <option value="mg">Madagascar</option>
 326             <option value="mh">Marshall Islands</option>
 327             <option value="mk">Macedonia</option>
 328             <option value="ml">Mali</option>
 329             <option value="mm">Myanmar</option>
 330             <option value="mn">Mongolia</option>
 331             <option value="mo">Macao</option>
 332             <option value="mp">Northern Mariana Islands</option>
 333             <option value="mq">Martinique</option>
 334             <option value="mr">Mauritania</option>
 335             <option value="ms">Montserrat</option>
 336             <option value="mt">Malta</option>
 337             <option value="mu">Mauritius</option>
 338             <option value="mv">Maldives</option>
 339             <option value="mw">Malawi</option>
 340             <option value="mx">Mexico</option>
 341             <option value="my">Malaysia</option>
 342             <option value="mz">Mozambique</option>
 343             <option value="na">Namibia</option>
 344             <option value="nc">New Caledonia</option>
 345             <option value="ne">Niger</option>
 346             <option value="nf">Norfolk Island</option>
 347             <option value="ng">Nigeria</option>
 348             <option value="ni">Nicaragua</option>
 349             <option value="nl">Netherlands</option>
 350             <option value="no">Norway</option>
 351             <option value="np">Nepal</option>
 352             <option value="nr">Nauru</option>
 353             <option value="nu">Niue</option>
 354             <option value="nz">New Zealand</option>
 355             <option value="om">Oman</option>
 356             <option value="pa">Panama</option>
 357             <option value="pe">Peru</option>
 358             <option value="pf">French Polynesia</option>
 359             <option value="pg">Papua New Guinea</option>
 360             <option value="ph">Philippines</option>
 361             <option value="pk">Pakistan</option>
 362             <option value="pl">Poland</option>
 363             <option value="pm">Saint Pierre and Miquelon</option>
 364             <option value="pn">Pitcairn</option>
 365             <option value="pr">Puerto Rico</option>
 366             <option value="ps">Palestinian Territory</option>
 367             <option value="pt">Portugal</option>
 368             <option value="pw">Palau</option>
 369             <option value="py">Paraguay</option>
 370             <option value="qa">Qatar</option>
 371             <option value="re">Reunion</option>
 372             <option value="ro">Romania</option>
 373             <option value="rs">Serbia</option>
 374             <option value="ru">Russian Federation</option>
 375             <option value="rw">Rwanda</option>
 376             <option value="sa">Saudi Arabia</option>
 377             <option value="sb">Solomon Islands</option>
 378             <option value="sc">Seychelles</option>
 379             <option value="sd">Sudan</option>
 380             <option value="se">Sweden</option>
 381             <option value="sg">Singapore</option>
 382             <option value="sh">Saint Helena</option>
 383             <option value="si">Slovenia</option>
 384             <option value="sj">Svalbard and Jan Mayen</option>
 385             <option value="sk">Slovakia</option>
 386             <option value="sl">Sierra Leone</option>
 387             <option value="sm">San Marino</option>
 388             <option value="sn">Senegal</option>
 389             <option value="so">Somalia</option>
 390             <option value="sr">Suriname</option>
 391             <option value="st">Sao Tome and Principe</option>
 392             <option value="sv">El Salvador</option>
 393             <option value="sy">Syrian Arab Republic</option>
 394             <option value="sz">Swaziland</option>
 395             <option value="tc">Turks and Caicos Islands</option>
 396             <option value="td">Chad</option>
 397             <option value="tf">French Southern Territories</option>
 398             <option value="tg">Togo</option>
 399             <option value="th">Thailand</option>
 400             <option value="tj">Tajikistan</option>
 401             <option value="tk">Tokelau</option>
 402             <option value="tl">Timor-Leste</option>
 403             <option value="tm">Turkmenistan</option>
 404             <option value="tn">Tunisia</option>
 405             <option value="to">Tonga</option>
 406             <option value="tr">Turkey</option>
 407             <option value="tt">Trinidad and Tobago</option>
 408             <option value="tv">Tuvalu</option>
 409             <option value="tw">Taiwan</option>
 410             <option value="tz">Tanzania United Republic of</option>
 411             <option value="ua">Ukraine</option>
 412             <option value="ug">Uganda</option>
 413             <option selected="" value="us">United States</option>
 414             <option value="um">United States Minor Outlying Islands</option>
 415             <option value="uy">Uruguay</option>
 416             <option value="uz">Uzbekistan</option>
 417             <option value="va">Holy See (Vatican City State)</option>
 418             <option value="vc">Saint Vincent and the Grenadines</option>
 419             <option value="ve">Venezuela</option>
 420             <option value="vg">Virgin Islands British</option>
 421             <option value="vi">Virgin Islands U.S.</option>
 422             <option value="vn">Vietnam</option>
 423             <option value="vu">Vanuatu</option>
 424             <option value="wf">Wallis and Futuna</option>
 425             <option value="ws">Samoa</option>
 426             <option value="ye">Yemen</option>
 427             <option value="yt">Mayotte</option>
 428             <option value="za">South Africa</option>
 429             <option value="zm">Zambia</option>
 430             <option value="zw">Zimbabwe</option>
 431           </select>
 432
 433         </div>
 434         <div class="formline">
 435           <label for="phone3"><span id="phone3_mobile_phone">Mobile Phone</span><span class="requiredText">*</span></label>
 436           <input type="number" pattern="[0-9]*" name="phonenumber" id="phone3" size="35" maxlength="140">
 437         </div>
 438       </fieldset>
 439
 440     </div>
 441   </div>
 442   <div class="pc">
 443     <div class="smalltext">Your order may be canceled without notice if you do not use the exact billing address of your credit card.<br>
 444
 445       <strong>Age Restrictions</strong><br>
 446       If you are under 13 years old you cannot provide us with any information about yourself. If you fill in this form, you represent that you are at least 13 years old.
 447     </div>
 448   </div>
 449   <div class="pc">
 450     <input type="submit" class="btn btn-primarycta btn-large" value="Save Card">
 451     <br><em>You will not be charged</em>
 452   </div>
 453 </form>