text: <!-- https://www.jbox.com/checkout/payment# -->
  <form name="paymentForm" method="post" action="#" id="paymentForm">
    <div id="errors"></div>
    <fieldset id="paymentchoose">
      <legend>Choose a payment method</legend>
      <div>
        <select id="paymentoption" accesskeyclass="element select medium" name="payment_method" onchange="changePayment()">
          <option selected="selected">
            Visa
          </option>
          <option>
            Mastercard
          </option>
          <option>
            American Express
          </option>
          <option>
            Discover
          </option>
          <option>
            Card on File (provide CVV2)
          </option>
          <option>
            Check / Money Order
          </option>
          <option>
            Gift Certificate / Credit
          </option>
          <option>
            Western Union (we'll send instructions)
          </option>
          <option value="PayPal">
            PayPal
          </option>
          <option value="Google Checkout">
            Google Checkout
          </option>
        </select>
      </div>
    </fieldset>
    <fieldset id="ccinput">
      <legend>Credit Card Details</legend>
      <div>
        <input name="cc_number" class="element text medium" type="text" maxlength="255" value=""> <label for="address1"><b>Credit Card Number</b></label>
      </div>
      <div>
        <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>
      </div>
      <div class="left">
        <span><input name="cc_exp" class="element text small" type="text" maxlength="255" value=""> <label for="cc_exp">Expiration date<br>
        (MM/YY)</label></span>
      </div>
      <div>
        <span><input name="cc_cvv2" class="element text small" type="text" maxlength="255" value=""> <label for="cc_cvv2">CVV2 / Security Code:</label></span>
      </div>
    </fieldset>
    <fieldset>
      <legend>If an item is not available:</legend> <select name="field_17">
        <option value="Select an option...">
          Select an option...
        </option>
        <option value="Cancel the item">
          Cancel the item
        </option>
        <option value="Wait for all items to be available">
          Wait for all items to be available
        </option>
        <option value="Split and send separately (additional fees apply)">
          Split and send separately (additional fees apply)
        </option>
      </select>
    </fieldset>
    <fieldset>
      <legend>Please confirm your age</legend> <input name="age" class="element text small" type="text" maxlength="255" value="">
    </fieldset>
    <fieldset>
      <legend>Comment or Special Instructions (if any)</legend>
      <textarea id="element_6" name="comments" class="element textarea small"></textarea>
    </fieldset><input type="hidden" name="paymentForm" value="259215"> <input id="placeorder" class="button_text" type="submit" name="submit" value="Place Order">
  </form>
  