<form method="post" action="https://www.cryptoheaven.com/ch/web-form.

jsp"
ENCTYPE="multipart/form-data">

<!-- required parameters CH_uId or CH_toEmail -->

<input type="hidden" name="CH_uId" value="3487961">

<!-- optional parameters CH_successPage and CH_errorPage -->

<input type="hidden" name="CH_successPage"
value="http://www.yourserver.com/success">
<input type="hidden" name="CH_errorPage" value="http://www.yourserver.com/error">

<!-- other optional parameters CH_fromName, CH_fromEmail CH_subject -->

<input type="hidden" name="CH_fromName" value="CryptoHeaven Secure Form">
<input type="hidden" name="CH_fromEmail" value="my-forms@cryptoheaven.com">
<input type="hidden" name="CH_subject" value="Your Site Payment Form">

<!-- your regular form follows -->

<table width=518 border="0" cellpadding="0" cellspacing="0" bgcolor="#FFFFFF">
  <tr bgcolor="#E5E5E5">
    <td height="22" colspan="3" align="left" valign="middle"><strong>&nbsp;Billing
Information (required)</strong></td>
  </tr>
  <tr>
    <td height="22" width="180" align="right" valign="middle">First Name:</td>
    <td colspan="2" align="left"><input name="firstName" type="text" size="50"></td>
  </tr>
  <tr>
    <td height="22" align="right" valign="middle">Last Name:</td>
    <td colspan="2" align="left"><input name="lastName" type="text" size="50"></td>
  </tr>
  <tr>
    <td height="22" align="right" valign="middle">Company (optional):</td>
    <td colspan="2" align="left"><input name="company" type="text" size="50"></td>
  </tr>
  <tr>
    <td height="22" align="right" valign="middle">Street Address:</td>
    <td colspan="2" align="left"><input name="address1" type="text" value=""
size="50"></td>
  </tr>
  <tr>
    <td height="22" align="right" valign="middle">Street Address (2):</td>
    <td colspan="2" align="left"><input name="address2" type="text" value=""
size="50"></td>
  </tr>
  <tr>
    <td height="22" align="right" valign="middle">City:</td>
    <td colspan="2" align="left"><input name="city" type="text" value="" size="50"></td>
  </tr>
  <tr>
    <td height="22" align="right" valign="middle">State/Province:</td>
    <td colspan="2" align="left"><input name="state" type="text" value="" size="50"></td>
  </tr>
  <tr>
    <td height="22" align="right" valign="middle">Zip/Postal Code:</td>
    <td colspan="2" align="left"><input name="zip" type="text" value="" size="50"></td>
  </tr>
  <tr>
    <td height="22" align="right" valign="middle">Country:</td>
    <td colspan="2" align="left"><input name="country" type="text" value=""
size="50"></td>
  </tr>
  <tr>
    <td height="22" align="right" valign="middle">Phone:</td>
    <td colspan="2" align="left"><input name="phone" type="text" value="" size="50"></td>
  </tr>
  <tr>
    <td height="22" colspan="3" align="left" valign="middle">&nbsp;</td>
  </tr>
  <tr bgcolor="#E5E5E5">
    <td height="22" colspan="3" align="left" valign="middle"><strong>&nbsp;Credit Card
(required)</strong></td>
  </tr>
  <tr>
    <td height="22" align="right" valign="middle">Credit Card Number:</td>
    <td colspan="2" align="left"><input name="CCNo" type="text" value="" size="19"
maxlength="40"></td>
  </tr>
  <tr>
    <td height="22" align="right" valign="middle">Expiry Date:</td>
    <td colspan="2" align="left">
      <SELECT NAME="CCExpiresMonth" >
        <OPTION VALUE="" SELECTED>--Month--
        <OPTION VALUE="01">January (01)
        <OPTION VALUE="02">February (02)
        <OPTION VALUE="03">March (03)
        <OPTION VALUE="04">April (04)
        <OPTION VALUE="05">May (05)
        <OPTION VALUE="06">June (06)
        <OPTION VALUE="07">July (07)
        <OPTION VALUE="08">August (08)
        <OPTION VALUE="09">September (09)
        <OPTION VALUE="10">October (10)
        <OPTION VALUE="11">November (11)
        <OPTION VALUE="12">December (12)
      </SELECT> /
      <SELECT NAME="CCExpiresYear">
        <OPTION VALUE="" SELECTED>--Year--
        <OPTION VALUE="04">2004
        <OPTION VALUE="05">2005
        <OPTION VALUE="06">2006
        <OPTION VALUE="07">2007
        <OPTION VALUE="08">2008
        <OPTION VALUE="09">2009
        <OPTION VALUE="10">2010
        <OPTION VALUE="11">2011
        <OPTION VALUE="12">2012
        <OPTION VALUE="13">2013
        <OPTION VALUE="14">2014
        <OPTION VALUE="15">2015
      </SELECT>
    </td>
  </tr>
  <tr>
    <td height="22" colspan="3" align="left" valign="middle">&nbsp;</td>
  </tr>
  <tr bgcolor="#E5E5E5">
    <td height="22" colspan="3" align="left" valign="middle"><strong>&nbsp;Additional
Information</strong></td>
  </tr>
  <tr>
    <td height="22" align="right" valign="middle">Contact Email:</td>
    <td colspan="2" align="left"><input name="contactEmail" type="text" value=""
size="50"></td>
  </tr>
  <tr>
    <td height="22" colspan="3" align="left" valign="middle">&nbsp;</td>
  </tr>
  <tr>
    <td height="22" align="right" valign="top">Special Notes:</td>
    <td colspan="2" align="left"><textarea name="notes" cols="45"
rows="4"></textarea></td>
  </tr>
</table>
<p><input name="Submit" type="submit" value="Send Secure Form &gt;&gt;"></p>
</form>