gecko-dev/extensions/wallet/editor/sample10.html

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<html>
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<TD WIDTH="294" VALIGN="BOTTOM" ALIGN="RIGHT">
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<TD colspan=3><IMG SRC="blank.gif" WIDTH="588" HEIGHT="4"></TD>
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<FORM>
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<TD BGCOLOR="#FFFF99">
<BR><BR>
<IMG SRC="blank.gif" WIDTH="20" HEIGHT="1" border="0"></td>
<TD COLSPAN=2 BGCOLOR="#FFFF99"><font size="-1" color="#000000"><b>Billing Information</b>&nbsp;<font color="#ff0000">(as it appears on your credit card statement)</font></font></td>
</TR>
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<TR>
<TD COLSPAN=3 BGCOLOR="#FFFF99" ALIGN="CENTER">
<table border="0" align="center"><tr><td valign="top">
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<TABLE border=0 CELLPADDING="0" BGCOLOR="#FFFF99">
<tr>
<td></td>
<tr>
<td align="right"><font size="-1">First&nbsp;Name</font></td>
<td> <input type=text name="Name.First" value="" size=20 maxlength=24></td>
</tr>
<tr>
<td align="right"><font size="-1">Last Name</font></td>
<td> <input type=text name="Name.Last" value="" size=20 maxlength=24></td>
</tr>
<tr>
<td align="right"><font size="-1">Address</font></td>
<td> <input type=text name="BillTo.Street.Line1" value="" size=20 maxlength=50></td>
</tr>
<tr>
<td align=right>&nbsp;</td>
<td> <input type=text name="BillTo.Street.Line2" value="" size=20 maxlength=50></td>
</tr>
<tr>
<td align="right"><font size="-1">City</font></td>
<td> <input type=text name="BillTo.City" value="" size=20 maxlength=50></td>
</tr>
<tr>
<td align="right" valign="middle"><font size="-1">State/Province</font></td>
<td valign="middle"><select name="BillTo.State" size="1">
<option value="--">(Req'd for US/Canada)</option>
<option value="AL" >Alabama</option>
<option value="AK" >Alaska</option>
<option value="AZ" >Arizona</option>
<option value="AR" >Arkansas</option>
<option value="CA" >California</option>
<option value="CO" >Colorado</option>
<option value="CT" >Connecticut</option>
<option value="DE" >Delaware</option>
<option value="DC" >District of Columbia</option>
<option value="FL" >Florida</option>
<option value="GA" >Georgia</option>
<option value="HI" >Hawaii</option>
<option value="ID" >Idaho</option>
<option value="IL" >Illinois</option>
<option value="IN" >Indiana</option>
<option value="IA" >Iowa</option>
<option value="KS" >Kansas</option>
<option value="KY" >Kentucky</option>
<option value="LA" >Louisiana</option>
<option value="ME" >Maine</option>
<option value="MD" >Maryland</option>
<option value="MA" >Massachusetts</option>
<option value="MI" >Michigan</option>
<option value="MN" >Minnesota</option>
<option value="MS" >Mississippi</option>
<option value="MO" >Missouri</option>
<option value="MT" >Montana</option>
<option value="NE" >Nebraska</option>
<option value="NV" >Nevada</option>
<option value="NH" >New Hampshire</option>
<option value="NJ" >New Jersey</option>
<option value="NM" >New Mexico</option>
<option value="NY" >New York</option>
<option value="NC" >North Carolina</option>
<option value="ND" >North Dakota</option>
<option value="OH" >Ohio</option>
<option value="OK" >Oklahoma</option>
<option value="OR" >Oregon</option>
<option value="PA" >Pennsylvania</option>
<option value="RI" >Rhode Island</option>
<option value="SC" >South Carolina</option>
<option value="SD" >South Dakota</option>
<option value="TN" >Tennessee</option>
<option value="TX" >Texas</option>
<option value="UT" >Utah</option>
<option value="VT" >Vermont</option>
<option value="VA" >Virginia</option>
<option value="WA" >Washington</option>
<option value="WV" >West Virginia</option>
<option value="WI" >Wisconsin</option>
<option value="WY" >Wyoming</option>
<option value=">------</option>
<option value="AS" >American Samoa</option>
<option value="GU" >Guam</option>
<option value="MH" >Marshall Islands</option>
<option value="FM" >Micronesia</option>
<option value="MP" >Northern Marianas</option>
<option value="PW" >Palau</option>
<option value="PR" >Puerto Rico</option>
<option value="TT" >Trust Territories</option>
<option value="VI" >Virgin Islands</option>
<option value="AA" >Armed Forces(AA)</option>
<option value="AE" >Armed Forces(AE)</option>
<option value="AP" >Armed Forces(AP)</option>
<option value=" ">------</option>
<option value="AB" >Alberta</option>
<option value="BC" >British Columbia</option>
<option value="MB" >Manitoba</option>
<option value="NB" >New Brunswick</option>
<option value="NF" >Newfoundland</option>
<option value="NT" >Northwest Territory</option>
<option value="NS" >Nova Scotia</option>
<option value="ON" >Ontario</option>
<option value="PE" >Prince Edward Island</option>
<option value="PQ" >Quebec</option>
<option value="SK" >Saskatchewan</option>
<option value="YT" >Yukon Territory</option>
</select></td>
</tr>
<tr>
<td align="right"><font SIZE="-1">Postal Code</font></td>
<td> <input type=text name="BillTo.PostalCode" value="" size=20 maxlength=20></font></td>
</tr>
<tr>
<td align="right"><font SIZE="-1">Country</font></td>
<td><select name="BillTo.Country" size="1">
<option value="001" >United States of America</option>
<option value="002" >Afghanistan</option>
<option value="003" >Albania</option>
<option value="004" >Algeria</option>
<option value="005" >Andorra</option>
<option value="006" >Angola</option>
<option value="007" >Anguilla</option>
<option value="008" >Antigua & Barbuda</option>
<option value="009" >Argentina</option>
<option value="010" >Aruba</option>
<option value="011" >Ascension</option>
<option value="012" >Australia</option>
<option value="013" >Austria</option>
<option value="014" >Azores</option>
<option value="015" >Bahamas</option>
<option value="016" >Bahrain</option>
<option value="017" >Bangladesh</option>
<option value="018" >Barbados</option>
<option value="019" >Belgium</option>
<option value="020" >Belize</option>
<option value="021" >Benin</option>
<option value="022" >Bermuda</option>
<option value="023" >Bhutan</option>
<option value="024" >Bolivia</option>
<option value="025" >Botswana</option>
<option value="026" >Brazil</option>
<option value="027" >British Virgin Islands</option>
<option value="028" >Brunei</option>
<option value="029" >Bulgaria</option>
<option value="030" >Burkina Faso</option>
<option value="031" >Burma</option>
<option value="032" >Burundi</option>
<option value="033" >Cameroon</option>
<option value="034" >Canada</option>
<option value="035" >Cape Verde</option>
<option value="036" >Cayman Islands</option>
<option value="037" >Central African Republic</option>
<option value="038" >Chad</option>
<option value="039" >Chile</option>
<option value="040" >China</option>
<option value="041" >Colombia</option>
<option value="042" >Comoros</option>
<option value="043" >Congo</option>
<option value="044" >Corsica</option>
<option value="045" >Costa Rica</option>
<option value="046" >Cote d'Ivoire</option>
<option value="047" >Cuba</option>
<option value="048" >Cyprus</option>
<option value="049" >Czechoslovakia</option>
<option value="050" >Denmark</option>
<option value="051" >Djibouti</option>
<option value="052" >Dominica</option>
<option value="053" >Dominican Rep.</option>
<option value="054" >East Timor</option>
<option value="055" >Ecuador</option>
<option value="056" >Egypt</option>
<option value="057" >El Salvador</option>
<option value="073" >England</option>
<option value="058" >Equatorial Guinea</option>
<option value="059" >Estonia</option>
<option value="060" >Ethiopia</option>
<option value="061" >Falkland Islands</option>
<option value="062" >Faroe Islands</option>
<option value="063" >Fiji</option>
<option value="064" >Finland</option>
<option value="065" >France</option>
<option value="066" >French Guiana</option>
<option value="067" >French Polynesia</option>
<option value="068" >Gabon</option>
<option value="069" >Gambia</option>
<option value="070" >Germany</option>
<option value="071" >Ghana</option>
<option value="072" >Gibraltar</option>
<option value="073" >Great Britain</option>
<option value="074" >Greece</option>
<option value="075" >Greenland</option>
<option value="076" >Grenada</option>
<option value="077" >Guadeloupe</option>
<option value="078" >Guatemala</option>
<option value="079" >Guinea</option>
<option value="080" >Guinea-Bissau</option>
<option value="081" >Guyana</option>
<option value="082" >Haiti</option>
<option value="083" >Honduras</option>
<option value="084" >Hong Kong</option>
<option value="085" >Hungary</option>
<option value="086" >Iceland</option>
<option value="087" >India</option>
<option value="088" >Indonesia</option>
<option value="089" >Iran</option>
<option value="090" >Iraq</option>
<option value="091" >Ireland</option>
<option value="092" >Israel</option>
<option value="093" >Italy</option>
<option value="094" >Jamaica</option>
<option value="095" >Japan</option>
<option value="096" >Jordan</option>
<option value="097" >Kampuchea</option>
<option value="098" >Kenya</option>
<option value="099" >Kiribati</option>
<option value="101" >Kuwait, Republic of</option>
<option value="102" >Laos</option>
<option value="103" >Latvia</option>
<option value="104" >Lebanon</option>
<option value="105" >Lesotho</option>
<option value="106" >Liberia</option>
<option value="107" >Libya</option>
<option value="108" >Liechtenstein</option>
<option value="109" >Lithuania</option>
<option value="110" >Luxembourg</option>
<option value="111" >Macau</option>
<option value="112" >Madagascar</option>
<option value="113" >Madeira Islands</option>
<option value="114" >Malawi</option>
<option value="115" >Malaysia</option>
<option value="116" >Maldives</option>
<option value="117" >Mali</option>
<option value="118" >Malta</option>
<option value="119" >Martinique</option>
<option value="120" >Mauritania</option>
<option value="121" >Mauritius</option>
<option value="122" >Mexico</option>
<option value="123" >Monaco</option>
<option value="124" >Mongolia</option>
<option value="125" >Montserrat</option>
<option value="126" >Morocco</option>
<option value="127" >Mozambique</option>
<option value="128" >Nauru</option>
<option value="129" >Nepal</option>
<option value="130" >Netherlands</option>
<option value="131" >Netherlands Antilies</option>
<option value="132" >New Caledonia</option>
<option value="133" >New Zealand</option>
<option value="134" >Nicaragua</option>
<option value="135" >Niger</option>
<option value="136" >Nigeria</option>
<option value="137" >Norway</option>
<option value="138" >Oman</option>
<option value="139" >Pakistan</option>
<option value="140" >Panama</option>
<option value="141" >Papua New Guinea</option>
<option value="142" >Paraguay</option>
<option value="143" >Peru</option>
<option value="144" >Philippines</option>
<option value="145" >Pitcairn Islands</option>
<option value="146" >Poland</option>
<option value="147" >Portugal</option>
<option value="148" >Qatar</option>
<option value="149" >Reunion</option>
<option value="150" >Romania</option>
<option value="151" >Russia</option>
<option value="152" >Rwanda</option>
<option value="153" >St. Christopher & Nevis</option>
<option value="154" >Saint Helena</option>
<option value="155" >Saint Lucia</option>
<option value="156" >Saint Pierre & Miquelon</option>
<option value="157" >St. Vincent&The Grenadines</option>
<option value="158" >San Marino</option>
<option value="159" >Sao Tome & Principe</option>
<option value="160" >Saudi Arabia</option>
<option value="161" >Senegal</option>
<option value="162" >Seychelles</option>
<option value="163" >Sierra Leone</option>
<option value="164" >Singapore</option>
<option value="165" >Solomon Islands</option>
<option value="166" >Somalia</option>
<option value="167" >South Africa</option>
<option value="168" >Spain</option>
<option value="169" >Sri Lanka</option>
<option value="170" >Sudan</option>
<option value="171" >Suriname</option>
<option value="172" >Swaziland</option>
<option value="173" >Sweden</option>
<option value="174" >Switzerland</option>
<option value="175" >Syria</option>
<option value="176" >Taiwan</option>
<option value="177" >Tanzania</option>
<option value="178" >Thailand</option>
<option value="179" >Togo</option>
<option value="180" >Tonga</option>
<option value="181" >Trinidad and Tobago</option>
<option value="182" >Tristan da Cunha</option>
<option value="183" >Tunisia</option>
<option value="184" >Turkey</option>
<option value="185" >Turks & Caicos Islands</option>
<option value="186" >Tuvalu</option>
<option value="187" >Wallis & Futuna Islands</option>
<option value="188" >Western Samoa</option>
<option value="189" >U.S.S.R.</option>
<option value="190" >Uganda</option>
<option value="191" >United Arab Emirates</option>
<option value="073" >United Kingdom</option>
<option value="192" >Uruguay</option>
<option value="193" >Vanuatu</option>
<option value="194" >Vatican City</option>
<option value="195" >Venezuela</option>
<option value="196" >Vietnam</option>
<option value="197" >Yemen</option>
<option value="198" >Yugoslavia</option>
<option value="199" >Zaire</option>
<option value="200" >Zambia</option>
<option value="201" >Zimbabwe</option>
<option value="202" >Korea, Republic of</option>
<option value="225" >Armenia</option>
<option value="226" >Azerbaijan</option>
<option value="227" >Byelorussia (Belarus)</option>
<option value="228" >Estonia</option>
<option value="229" >Republic of Georgia</option>
<option value="230" >Kazakhstan</option>
<option value="231" >Kirghizia (Kyrgyzstan)</option>
<option value="232" >La Luia</option>
<option value="233" >Lithuania</option>
<option value="234" >Moldova</option>
<option value="235" >Tadzhikistan</option>
<option value="236" >Turkmenistan</option>
<option value="237" >Ukraine</option>
<option value="238" >Uzbekistan</option>
<option value="239" >Bosnia (Hercgovina)</option>
<option value="240" >Croatia</option>
<option value="241" >Servia (Montenegro)</option>
<option value="242" >Macedonia</option>
<option value="243" >Slovenia</option>
<option value="244" >Slovakia</option>
<option value="245" >Czech Republic</option>
<option value="246" >Scotland</option>
<option value="247" >Canary Islands</option>
</select></td>
</tr>
</table>
</td>
<!-- Right hand side information box-->
<td valign="top">
<TABLE border=0 CELLPADDING="0" BGCOLOR="#FFFF99">
<td colspan="2" align=right><font size="-1">Phone</font>&nbsp;<input type=text name="BillTo.Phone" value="" size=20 maxlength=100>&nbsp;</td>
</tr>
<tr>
<td colspan="2" align=right><font size="-1">E-mail&nbsp;Address</font>&nbsp;<input type=text name="BillTo.Email" value="" size=20 maxlength=50>&nbsp;</td>
</tr>
<tr>
<td><br><font size="-2" color=red>We cannot ship to a Post Office box.<BR>Please enter a street address.</font></td>
</tr>
<tr>
<td colspan="2" align="right"><font size="-1"><br>Company</font>
<input type=text name="BillTo.CompanyName" value="" size=20 maxlength=50>
</td>
</tr>
<tr><td align="right" valign="top" colspan="2"><font size="-2" color=red>Leave blank unless using a company credit card.</font><br><br></td></tr>
<tr>
<td colspan="2" ALIGN="LEFT"><nobr><font size="2">&nbsp;&nbsp;
<input type=radio name="checkout%bill.shiptobill" value="1"checked> Ship my order to this address.</td>
</tr>
<tr>
<td colspan="2" ALIGN="LEFT"><nobr><font size="2">&nbsp;&nbsp;
<input type=radio name="checkout%bill.shiptobill" value="0"> Ship my order to a different address.</font>
</td>
</tr>
</table>
</td>
</tr>
</table>
</td></tr>
<!-- Form Input Fields End Here -->
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<td colspan=3>
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<tr><td><input type="submit" value="Continue"></td></tr>
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</FORM>
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</body>
</html>