Source/HTML Code

<form id="weborder" name="weborder" method="post" action="https://secure.quantumgateway.com/cgi/web_order.php">
<table width="100%" border="0" cellspacing="2" cellpadding="2">
<tr>
<td colspan="2"><strong>Billing info</strong></td>
</tr>
<tr>
<td width="20%"><div align="right"><strong>First Name</strong></div></td>
<td>
<input type="text" name="FNAME" id="FNAME" /> </td>
</tr>
<tr>
<td width="20%"><div align="right"><strong>Last Name</strong></div></td>
<td><input type="text" name="LNAME" id="LNAME" /></td>
</tr>
<tr>
<td width="20%"><div align="right"><strong>Address </strong></div></td>
<td><input type="text" name="BADDR1" id="BADDR1" /></td>
</tr>
<tr>
<td width="20%"><div align="right"><strong>City </strong></div></td>
<td><input type="text" name="BCITY" id="BCITY" /></td>
</tr>
<tr>
<td width="20%"><div align="right"><strong>State </strong></div></td>
<td><input type="text" name="BSTATE" id="BSTATE" /></td>
</tr>
<tr>
<td width="20%"><div align="right"><strong>Zip </strong></div></td>
<td><input type="text" name="BZIP1" id="BZIP1" /></td>
</tr>
<tr>
<td width="20%"><div align="right"><strong>Country </strong></div></td>
<td><input type="text" name="BCOUNTRY" id="BCOUNTRY" /></td>
</tr>
<tr>
<td width="20%"><div align="right"><strong>Phone </strong></div></td>
<td><input type="text" name="phone" id="phone" /></td>
</tr>
<tr>
<td width="20%"><div align="right"><strong>Email</strong></div></td>
<td>
<input type="text" name="BCUST_EMAIL" id="BCUST_EMAIL" /> </td>
</tr>
<tr>
<td colspan="2"><strong>Shipping Info</strong></td>
</tr>
<tr>
<td><div align="right"><strong>First Name</strong></div></td>
<td><input type="text" name="SFNAME" id="SFNAME" /></td>
</tr>
<tr>
<td><div align="right"><strong>Last Name</strong></div></td>
<td><input type="text" name="SLNAME" id="SLNAME" /></td>
</tr>
<tr>
<td><div align="right"><strong>Address</strong></div></td>
<td><input type="text" name="SADDR1" id="SADDR1" /></td>
</tr>
<tr>
<td><div align="right"><strong>City</strong></div></td>
<td><input type="text" name="SCITY" id="SCITY" /></td>
</tr>
<tr>
<td><div align="right"><strong>State</strong></div></td>
<td><input type="text" name="SSTATE" id="SSTATE" /></td>
</tr>
<tr>
<td width="20%"><div align="right"><strong>Zip</strong></div></td>
<td><input type="text" name="SZIP1" id="SZIP1" /></td>
</tr>
<tr>
<td><div align="right"><strong>Country</strong></div></td>
<td><input type="text" name="SCOUNTRY" id="SCOUNTRY" /></td>
</tr>
<tr>
<td>&nbsp;</td>
<td>&nbsp;</td>
</tr>
<tr>
<td><div align="right"><strong>AMOUNT</strong></div></td>
<td>$
<input name="item_cost" type="text" id="item_cost" value="1.00" /></td>
</tr>
<tr>
<td width="20%">&nbsp;</td>
<td> <input name="gwlogin" type="hidden" value="your_gateway_login">
<input name="post_return_url_approved" type="hidden" value="http://www.mydomain.com/approved.html">
<input name="post_return_url_declined" type="hidden" value="http://www.mydomain.com/declined.html">
<input name="item_qty" type="hidden" value="1">
<input name="item_description" type="hidden" value="One year subscription to http://www.mydomain.com">
<input name="override_email_customer" type="hidden" value="Y">
<input name="override_trans_email" type="hidden" value="Y">
<input type="submit" name="button" id="button" value="Checkout" />
&nbsp;&nbsp;&nbsp;
<input type="reset" name="button2" id="button2" value="Reset" /></td>
</tr>
</table>

</form>