<form action="https://www.secure-server-hosting.com/secutran/transactionsi1.php" method="post" name="basketform" id="basketform" onsubmit="return validateForm(this)">
    <input type="hidden" name='shreference' value='$shreference' />
    <input type="hidden" name='checkcode' value='$checkcode' />
    <input type="hidden" name='secuitems' value='$secuitems' />
    <input type="hidden" name='transactioncurrency' value='$transactioncurrency' />
    <input type="hidden" name='shippingcharge' value='$shippingcharge' />
    <input type="hidden" name='transactiontax' value='$transactiontax' />
    <input type="hidden" name='transactionamount' value='$transactionamount' />
    <input type="hidden" name="filename" value="$backfile" />
    Name: <input type="text" name="cardholdersname" /><br />
    Email address: <input type="text" name="cardholdersemail" /><br />
    Phone number: <input type="text" name="cardholdertelephonenumber" /><br />
    Street: <input type="text" name="cardholderaddr1" /><br />
    City/Town: <input type="text" name="cardholdercity" /><br />
    County: <input type="text" name="cardholderstate" /><br />
    Postcode: <input type="text" name="cardholderpostcode" /><br />
    Card number: <input type="text" name="cardnumber" /><br />
    Expiry date: <select name="cardexpiremonth">
        <option value="01">01</option>
        <option value="02">02</option>
        <option value="03">03</option>
        <option value="04">04</option>
        <option value="05">05</option>
        <option value="06">06</option>
        <option value="07">07</option>
        <option value="08">08</option>
        <option value="09">09</option>
        <option value="10">10</option>
        <option value="11">11</option>
        <option value="12">12</option>
    </select> / <select name="cardexpireyear">
        <option value="17">17</option>
        <option value="18">18</option>
        <option value="19">19</option>
        <option value="20">20</option>
        <option value="21">21</option>
        <option value="22">22</option>
        <option value="23">23</option>
        <option value="24">24</option>
        <option value="25">25</option>
    </select><br />
    CV2 number: <input type="text" name="cv2" />
</form>

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