Gracias:
Código HTML:
<form METHOD="post" ACTION="send_pledge.php"> <div align="left"><table width="69%" border="0" align="center" cellpadding="3" cellspacing="3"> <tr> <td width="50%" align="right"><span class="style5"><font color="#000000"><small>Name</small></font></span></td> <td width="50%"><font color="#FFFFFF" face="Arial"><input type="text" name="name"size="40"></font></td> </tr> <tr> <td width="50%" align="right"><div align="right"><p class="style5"><font color="#000000"><small>Billing address</small></font></td> <td width="50%"><font color="#FFFFFF" face="Arial"><input type="text" name="billing"size="40"></font></td> </tr> <tr> <td width="50%" align="right"><span class="style5">City</span></td> <td width="50%"><font color="#FFFFFF" face="Arial"><input type="text" name="city"size="40"></font></td> </tr> <tr> <td width="50%" align="right"><span class="style5">State</span></td> <td width="50%"><font color="#FFFFFF" face="Arial"><input type="text" name="state"size="40"></font></td> </tr> <tr> <td width="50%" align="right"><span class="style5"><font color="#000000"><small>Zip Code</small></font></span></td> <td width="50%"><font color="#FFFFFF" face="Arial"><input type="text" name="zip_code"size="40"> </font></td> </tr> <tr> <td width="50%" align="right"><span class="style5">Telephone (home)</span></td> <td width="50%"><font color="#FFFFFF" face="Arial"><input type="text" name="phone_home"size="40" id="phone_home"> </font></td> </tr> <tr> <td width="24%" align="right"><span class="style5">Telephone (business)</span></td> <td width="28%"><font color="#FFFFFF" face="Arial"><input type="text" name="phone_business"size="40" id="phone_business"> </font></td> </tr> <tr> <td width="20%" align="right"><span class="style5">Fax</span></td> <td width="28%"><font color="#FFFFFF" face="Arial"><input type="text" name="fax"size="40"> </font></td> </tr> <tr> <td width="24%" align="right"><span class="style5">E-Mail</span></td> <td width="28%"><font color="#FFFFFF" face="Arial"><input type="text" name="email"size="40"> </font></td> </tr> </table> <br> <br> <table align="center"> <td><div> <div align="center"><strong>Pledge Information</strong><br> </div> <p>I (we) pledge a total of $ <input name="amount" type="text" size="7" maxlength="10"> to be paid:<br> </p> <table width="200"> <tr> <td><span class="style5"> <label> <input type="radio" name="time" value="now" id="RadioGroup1_0"> Now</label> </span></td> </tr> <tr> <td><span class="style5"> <label> <input type="radio" name="time" value="monthly" id="RadioGroup1_1"> monthly</label> </span></td> </tr> <tr> <td><span class="style5"> <label> <input type="radio" name="time" value="quarterly" id="RadioGroup1_2"> quarterly</label> </span></td> </tr> <tr> <td><span class="style5"> <label> <input type="radio" name="time" value="yearly" id="RadioGroup1_3"> yearly</label> </span></td> </tr> </table> <p><br> I (we) plan to make this contribution in the form of:<br> </p> <table width="200"> <tr> <td><span class="style5"> <label> <input type="radio" name="plan" value="cash" id="RadioGroup2_0"> Cash</label> </span></td> </tr> <tr> <td><span class="style5"> <label> <input type="radio" name="plan" value="check" id="RadioGroup2_1"> Check</label> </span></td> </tr> <tr> <td><span class="style5"> <label> <input type="radio" name="plan" value="creditcard" id="RadioGroup2_2"> Credit Card</label> </span></td> </tr> <tr> <td><span class="style5"> <label> <input type="radio" name="plan" value="other" id="RadioGroup2_3"> Other</label> </span></td> </tr> </table> </div></td> </table> <br> <div align="left"><table width="69%" border="0" align="center" cellpadding="3" cellspacing="3"> <tr> <td width="50%" align="right"><span class="style5 style5">Credit card type</span></td> <td width="50%"><font color="#FFFFFF" face="Arial"><input type="text" name="card_type"size="40" id="card_type"> </font></td> </tr> <tr> <td width="50%" align="right"><div align="right"><p class="style5 style5">Credit card number</td> <td width="50%"><font color="#FFFFFF" face="Arial"><input type="text" name="card_number"size="40" id="card_number"> </font></td> </tr> <tr> <td width="50%" align="right"><span class="style5">Expiration date</span></td> <td width="50%"><font color="#FFFFFF" face="Arial"><input type="text" name="expiration_date"size="40"></font></td> </tr> <tr> <td width="50%" align="right"><span class="style5">Authorized signature</span></td> <td width="50%"><font color="#FFFFFF" face="Arial"><input type="text" name="signature"size="40" id="signature"> </font></td> </tr> </table> <table align="center"> <td> <div> <p>Gift will be matched by <input name="gift" type="text" size="20" maxlength="20"> </p> <p>(company/family/foundation). <input name="company" type="text" size="20" maxlength="20" id="company"> </p> <p>Form enclosed <input name="enclosed" type="text" size="20" maxlength="20" id="enclosed"> form will be forwarded. </p> <p class="style1"> Acknowledgement Information </p> <p>Please use the following name(s) in all acknowledgements: </p> <label> <input name="all_name" type="text" id="all_name" size="30" maxlength="35"> </label> <br> <p>I (we) wish to have our gift remain anonymous. </p> <label>Signature(s) <input name="signature2" type="text" id="signature2" size="30" maxlength="30"> </label><br><br> <label> Date <input name="date" type="text" id="date" size="30" maxlength="35"> </label> <div align="center"><br> <strong>Please make checks, corporate matches, or other gifts payable to:</strong><br><br> <em>DHails Community Ehancement Services, Inc.<br> 2101 Vista Parkway, Ste. #255<BR> West Palm Beach, Florida 33411 </em> </div> </div></td></table> <p align="center"> <label> <input type="submit" value="Submit"> </label> </p> </div> </form>