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Mar 31st, 2017
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  1. <form id="give-form-364" class="give-form give-form-364 give-form-type-multi float-labels-enabled give-recurring-form"
  2. action="http://www.esrevenge.org/african-painted-dog-project?payment-mode=twocheckout" method="post">
  3. <input type="hidden" name="give-form-id" value="364"/>
  4. <input type="hidden" name="give-form-title" value="African Dog Project"/>
  5. <input type="hidden" name="give-current-url"
  6. value="http://www.esrevenge.org/african-painted-dog-project"/>
  7. <input type="hidden" name="give-form-url"
  8. value="http://www.esrevenge.org/african-painted-dog-project"/>
  9. <input type="hidden" name="give-form-minimum"
  10. value="1.00"/>
  11.  
  12. <!-- The following field is for robots only, invisible to humans: -->
  13. <span class="give-hidden" style="display: none !important;">
  14. <label for="give-form-honeypot-364"></label>
  15. <input id="give-form-honeypot-364" type="text" name="give-honeypot"
  16. class="give-honeypot give-hidden"/>
  17. </span>
  18.  
  19. <input type="hidden" name="give-price-id" value="2"/>
  20. <div class="give-total-wrap">
  21. <div class="give-donation-amount form-row-wide">
  22. <span class="give-currency-symbol give-currency-position-before">$</span> <label class="give-hidden" for="give-amount">Donation Amount:</label>
  23. <input class="give-text-input give-amount-top" id="give-amount" name="give-amount" type="tel"
  24. placeholder="" value="10.00" autocomplete="off">
  25. </div>
  26. </div>
  27. <ul id="give-donation-level-button-wrap" class="give-donation-levels-wrap give-list-inline"><li><button type="button" data-price-id="1" class=" give-donation-level-btn give-btn give-btn-level-1 " value="5.00">$5.00</button></li><li><button type="button" data-price-id="2" class=" give-donation-level-btn give-btn give-btn-level-2 give-default-level" value="10.00">$10.00</button></li><li><button type="button" data-price-id="3" class=" give-donation-level-btn give-btn give-btn-level-3 " value="20.00">$20.00</button></li><li><button type="button" data-price-id="4" class=" give-donation-level-btn give-btn give-btn-level-4 " value="50.00">$50.00</button></li><li><button type="button" data-price-id="5" class=" give-donation-level-btn give-btn give-btn-level-5 " value="100.00">$100.00</button></li><li><button type="button" data-price-id="6" class=" give-donation-level-btn give-btn give-btn-level-6 " value="200.00">$200.00</button></li><li><button type="button" data-price-id="7" class=" give-donation-level-btn give-btn give-btn-level-7 " value="500.00">$500.00</button></li><li><button type="button" data-price-id="custom" class="give-donation-level-btn give-btn give-btn-level-custom" value="custom">Other</button></li></ul>
  28. <div class="give-recurring-donors-choice">
  29.  
  30. <input id="give-monthly-364" name="give-recurring-period" type="checkbox" value="give_month_0_times"/>
  31.  
  32. <label for="give-monthly-364">
  33. Make this Donation Monthly </label>
  34.  
  35. </div>
  36.  
  37. <button type="button" class="give-btn give-btn-modal">Donate Now</button>
  38. <fieldset id="give-payment-mode-select" >
  39. <legend
  40. class="give-payment-mode-label">Select Payment Method <span class="give-loading-text"><span
  41. class="give-loading-animation"></span>
  42. </span>
  43. </legend>
  44.  
  45. <div id="give-payment-mode-wrap">
  46. <ul id="give-gateway-radio-list">
  47. <li>
  48. <input type="radio" name="payment-mode" class="give-gateway"
  49. id="give-gateway-paypal-364"
  50. value="paypal">
  51. <label for="give-gateway-paypal-364"
  52. class="give-gateway-option"
  53. id="give-gateway-option-paypal"> PayPal</label>
  54. </li>
  55. <li class="give-gateway-option-selected">
  56. <input type="radio" name="payment-mode" class="give-gateway"
  57. id="give-gateway-twocheckout-364"
  58. value="twocheckout" checked='checked'>
  59. <label for="give-gateway-twocheckout-364"
  60. class="give-gateway-option"
  61. id="give-gateway-option-twocheckout"> Credit Card</label>
  62. </li>
  63. </ul>
  64. </div>
  65. </fieldset>
  66.  
  67.  
  68. <div id="give_purchase_form_wrap">
  69.  
  70. <fieldset id="give_checkout_user_info">
  71. <legend>Personal Info</legend>
  72. <p id="give-first-name-wrap" class="form-row form-row-first form-row-responsive">
  73. <label class="give-label" for="give-first">
  74. First Name <span class="give-required-indicator">*</span>
  75. <span class="give-tooltip give-icon give-icon-question"
  76. data-tooltip="We will use this to personalize your account experience."></span>
  77. </label>
  78. <input
  79. class="give-input required"
  80. type="text"
  81. name="give_first"
  82. placeholder="First Name"
  83. id="give-first"
  84. value=""
  85. required aria-required="true" />
  86. </p>
  87.  
  88. <p id="give-last-name-wrap" class="form-row form-row-last form-row-responsive">
  89. <label class="give-label" for="give-last">
  90. Last Name <span class="give-tooltip give-icon give-icon-question"
  91. data-tooltip="We will use this as well to personalize your account experience."></span>
  92. </label>
  93.  
  94. <input
  95. class="give-input"
  96. type="text"
  97. name="give_last"
  98. id="give-last"
  99. placeholder="Last Name"
  100. value=""
  101. />
  102. </p>
  103.  
  104. <p id="give-email-wrap" class="form-row form-row-wide">
  105. <label class="give-label" for="give-email">
  106. Email Address <span class="give-required-indicator">*</span>
  107. <span class="give-tooltip give-icon give-icon-question"
  108. data-tooltip="We will send the donation receipt to this address."></span>
  109. </label>
  110.  
  111. <input
  112. class="give-input required"
  113. type="email"
  114. name="give_email"
  115. placeholder="Email Address"
  116. id="give-email"
  117. value="pgottesman@yahoo.com"
  118. required aria-required="true" />
  119.  
  120. </p>
  121. </fieldset>
  122. <fieldset id="give_cc_fields-364" class="give-do-validate">
  123. <legend>Credit Card Info</legend>
  124. <p id="give-card-number-wrap-364" class="form-row form-row-two-thirds form-row-responsive">
  125. <label for="card_number-364" class="give-label">
  126. Card Number <span class="give-required-indicator">*</span>
  127. <span class="give-tooltip give-icon give-icon-question"
  128. data-tooltip="The (typically) 16 digits on the front of your credit card."></span>
  129. <span class="card-type"></span>
  130. </label>
  131.  
  132. <input type="tel" autocomplete="off" name="card_number" id="card_number-364"
  133. class="card-number give-input required" placeholder="Card number"
  134. required aria-required="true"/>
  135. </p>
  136.  
  137. <p id="give-card-cvc-wrap-364" class="form-row form-row-one-third form-row-responsive">
  138. <label for="card_cvc-364" class="give-label">
  139. CVC <span class="give-required-indicator">*</span>
  140. <span class="give-tooltip give-icon give-icon-question"
  141. data-tooltip="The 3 digit (back) or 4 digit (front) value on your card."></span>
  142. </label>
  143.  
  144. <input type="tel" size="4" autocomplete="off" name="card_cvc" id="card_cvc-364"
  145. class="card-cvc give-input required" placeholder="Security code"
  146. required aria-required="true"/>
  147. </p>
  148.  
  149. <p id="give-card-name-wrap-364" class="form-row form-row-two-thirds form-row-responsive">
  150. <label for="card_name-364" class="give-label">
  151. Name on the Card <span class="give-required-indicator">*</span>
  152. <span class="give-tooltip give-icon give-icon-question"
  153. data-tooltip="The name printed on the front of your credit card."></span>
  154. </label>
  155.  
  156. <input type="text" autocomplete="off" name="card_name" id="card_name-364"
  157. class="card-name give-input required" placeholder="Card name"
  158. required aria-required="true"/>
  159. </p>
  160. <p class="card-expiration form-row form-row-one-third form-row-responsive">
  161. <label for="card_expiry-364" class="give-label">
  162. Expiration <span class="give-required-indicator">*</span>
  163. <span class="give-tooltip give-icon give-icon-question"
  164. data-tooltip="The date your credit card expires, typically on the front of the card."></span>
  165. </label>
  166.  
  167. <input type="hidden" id="card_exp_month-364" name="card_exp_month"
  168. class="card-expiry-month"/>
  169. <input type="hidden" id="card_exp_year-364" name="card_exp_year"
  170. class="card-expiry-year"/>
  171.  
  172. <input type="tel" autocomplete="off" name="card_expiry" id="card_expiry-364"
  173. class="card-expiry give-input required" placeholder="MM / YY"
  174. required aria-required="true"/>
  175. </p>
  176. </fieldset>
  177. <fieldset id="give_cc_address" class="cc-address">
  178. <legend>Billing Details</legend>
  179. <p id="give-card-address-wrap" class="form-row form-row-wide">
  180. <label for="card_address" class="give-label">
  181. Address 1 <span class="give-required-indicator">*</span>
  182. <span class="give-tooltip give-icon give-icon-question"
  183. data-tooltip="The primary billing address for your credit card."></span>
  184. </label>
  185.  
  186. <input
  187. type="text"
  188. id="card_address"
  189. name="card_address"
  190. class="card-address give-input required"
  191. placeholder="Address line 1"
  192. value=""
  193. required aria-required="true" />
  194. </p>
  195.  
  196. <p id="give-card-address-2-wrap" class="form-row form-row-wide">
  197. <label for="card_address_2" class="give-label">
  198. Address 2 <span class="give-tooltip give-icon give-icon-question"
  199. data-tooltip="(optional) The suite, apt no, PO box, etc, associated with your billing address."></span>
  200. </label>
  201.  
  202. <input
  203. type="text"
  204. id="card_address_2"
  205. name="card_address_2"
  206. class="card-address-2 give-input"
  207. placeholder="Address line 2"
  208. value=""
  209. />
  210. </p>
  211.  
  212. <p id="give-card-city-wrap" class="form-row form-row-first form-row-responsive">
  213. <label for="card_city" class="give-label">
  214. City <span class="give-required-indicator">*</span>
  215. <span class="give-tooltip give-icon give-icon-question"
  216. data-tooltip="The city for your billing address."></span>
  217. </label>
  218. <input
  219. type="text"
  220. id="card_city"
  221. name="card_city"
  222. class="card-city give-input required"
  223. placeholder="City"
  224. value=""
  225. required aria-required="true" />
  226. </p>
  227.  
  228. <p id="give-card-zip-wrap" class="form-row form-row-last form-row-responsive">
  229. <label for="card_zip" class="give-label">
  230. Zip / Postal Code <span class="give-required-indicator">*</span>
  231. <span class="give-tooltip give-icon give-icon-question"
  232. data-tooltip="The zip or postal code for your billing address."></span>
  233. </label>
  234.  
  235. <input
  236. type="text"
  237. size="4"
  238. id="card_zip"
  239. name="card_zip"
  240. class="card-zip give-input required"
  241. placeholder="Zip / Postal Code"
  242. value=""
  243. required aria-required="true" />
  244. </p>
  245.  
  246. <p id="give-card-country-wrap" class="form-row form-row-first form-row-responsive">
  247. <label for="billing_country" class="give-label">
  248. Country <span class="give-required-indicator">*</span>
  249. <span class="give-tooltip give-icon give-icon-question"
  250. data-tooltip="The country for your billing address."></span>
  251. </label>
  252.  
  253. <select
  254. name="billing_country"
  255. id="billing_country"
  256. class="billing-country billing_country give-select required"
  257. required aria-required="true" >
  258. <option value=""></option><option value="US" selected='selected'>United States</option><option value="CA">Canada</option><option value="GB">United Kingdom</option><option value="AF">Afghanistan</option><option value="AL">Albania</option><option value="DZ">Algeria</option><option value="AS">American Samoa</option><option value="AD">Andorra</option><option value="AO">Angola</option><option value="AI">Anguilla</option><option value="AQ">Antarctica</option><option value="AG">Antigua and Barbuda</option><option value="AR">Argentina</option><option value="AM">Armenia</option><option value="AW">Aruba</option><option value="AU">Australia</option><option value="AT">Austria</option><option value="AZ">Azerbaijan</option><option value="BS">Bahamas</option><option value="BH">Bahrain</option><option value="BD">Bangladesh</option><option value="BB">Barbados</option><option value="BY">Belarus</option><option value="BE">Belgium</option><option value="BZ">Belize</option><option value="BJ">Benin</option><option value="BM">Bermuda</option><option value="BT">Bhutan</option><option value="BO">Bolivia</option><option value="BA">Bosnia and Herzegovina</option><option value="BW">Botswana</option><option value="BV">Bouvet Island</option><option value="BR">Brazil</option><option value="IO">British Indian Ocean Territory</option><option value="BN">Brunei Darrussalam</option><option value="BG">Bulgaria</option><option value="BF">Burkina Faso</option><option value="BI">Burundi</option><option value="KH">Cambodia</option><option value="CM">Cameroon</option><option value="CV">Cape Verde</option><option value="KY">Cayman Islands</option><option value="CF">Central African Republic</option><option value="TD">Chad</option><option value="CL">Chile</option><option value="CN">China</option><option value="CX">Christmas Island</option><option value="CC">Cocos Islands</option><option value="CO">Colombia</option><option value="KM">Comoros</option><option value="CD">Congo, Democratic People&#039;s Republic</option><option value="CG">Congo, Republic of</option><option value="CK">Cook Islands</option><option value="CR">Costa Rica</option><option value="CI">Cote d&#039;Ivoire</option><option value="HR">Croatia/Hrvatska</option><option value="CU">Cuba</option><option value="CY">Cyprus Island</option><option value="CZ">Czech Republic</option><option value="DK">Denmark</option><option value="DJ">Djibouti</option><option value="DM">Dominica</option><option value="DO">Dominican Republic</option><option value="TP">East Timor</option><option value="EC">Ecuador</option><option value="EG">Egypt</option><option value="GQ">Equatorial Guinea</option><option value="SV">El Salvador</option><option value="ER">Eritrea</option><option value="EE">Estonia</option><option value="ET">Ethiopia</option><option value="FK">Falkland Islands</option><option value="FO">Faroe Islands</option><option value="FJ">Fiji</option><option value="FI">Finland</option><option value="FR">France</option><option value="GF">French Guiana</option><option value="PF">French Polynesia</option><option value="TF">French Southern Territories</option><option value="GA">Gabon</option><option value="GM">Gambia</option><option value="GE">Georgia</option><option value="DE">Germany</option><option value="GR">Greece</option><option value="GH">Ghana</option><option value="GI">Gibraltar</option><option value="GL">Greenland</option><option value="GD">Grenada</option><option value="GP">Guadeloupe</option><option value="GU">Guam</option><option value="GT">Guatemala</option><option value="GG">Guernsey</option><option value="GN">Guinea</option><option value="GW">Guinea-Bissau</option><option value="GY">Guyana</option><option value="HT">Haiti</option><option value="HM">Heard and McDonald Islands</option><option value="VA">Holy See (City Vatican State)</option><option value="HN">Honduras</option><option value="HK">Hong Kong</option><option value="HU">Hungary</option><option value="IS">Iceland</option><option value="IN">India</option><option value="ID">Indonesia</option><option value="IR">Iran</option><option value="IQ">Iraq</option><option value="IE">Ireland</option><option value="IM">Isle of Man</option><option value="IL">Israel</option><option value="IT">Italy</option><option value="JM">Jamaica</option><option value="JP">Japan</option><option value="JE">Jersey</option><option value="JO">Jordan</option><option value="KZ">Kazakhstan</option><option value="KE">Kenya</option><option value="KI">Kiribati</option><option value="KW">Kuwait</option><option value="KG">Kyrgyzstan</option><option value="LA">Lao People&#039;s Democratic Republic</option><option value="LV">Latvia</option><option value="LB">Lebanon</option><option value="LS">Lesotho</option><option value="LR">Liberia</option><option value="LY">Libyan Arab Jamahiriya</option><option value="LI">Liechtenstein</option><option value="LT">Lithuania</option><option value="LU">Luxembourg</option><option value="MO">Macau</option><option value="MK">Macedonia</option><option value="MG">Madagascar</option><option value="MW">Malawi</option><option value="MY">Malaysia</option><option value="MV">Maldives</option><option value="ML">Mali</option><option value="MT">Malta</option><option value="MH">Marshall Islands</option><option value="MQ">Martinique</option><option value="MR">Mauritania</option><option value="MU">Mauritius</option><option value="YT">Mayotte</option><option value="MX">Mexico</option><option value="FM">Micronesia</option><option value="MD">Moldova, Republic of</option><option value="MC">Monaco</option><option value="MN">Mongolia</option><option value="ME">Montenegro</option><option value="MS">Montserrat</option><option value="MA">Morocco</option><option value="MZ">Mozambique</option><option value="MM">Myanmar</option><option value="NA">Namibia</option><option value="NR">Nauru</option><option value="NP">Nepal</option><option value="NL">Netherlands</option><option value="AN">Netherlands Antilles</option><option value="NC">New Caledonia</option><option value="NZ">New Zealand</option><option value="NI">Nicaragua</option><option value="NE">Niger</option><option value="NG">Nigeria</option><option value="NU">Niue</option><option value="NF">Norfolk Island</option><option value="KP">North Korea</option><option value="MP">Northern Mariana Islands</option><option value="NO">Norway</option><option value="OM">Oman</option><option value="PK">Pakistan</option><option value="PW">Palau</option><option value="PS">Palestinian Territories</option><option value="PA">Panama</option><option value="PG">Papua New Guinea</option><option value="PY">Paraguay</option><option value="PE">Peru</option><option value="PH">Phillipines</option><option value="PN">Pitcairn Island</option><option value="PL">Poland</option><option value="PT">Portugal</option><option value="PR">Puerto Rico</option><option value="QA">Qatar</option><option value="RE">Reunion Island</option><option value="RO">Romania</option><option value="RU">Russian Federation</option><option value="RW">Rwanda</option><option value="SH">Saint Helena</option><option value="KN">Saint Kitts and Nevis</option><option value="LC">Saint Lucia</option><option value="PM">Saint Pierre and Miquelon</option><option value="VC">Saint Vincent and the Grenadines</option><option value="SM">San Marino</option><option value="ST">Sao Tome and Principe</option><option value="SA">Saudi Arabia</option><option value="SN">Senegal</option><option value="RS">Serbia</option><option value="SC">Seychelles</option><option value="SL">Sierra Leone</option><option value="SG">Singapore</option><option value="SK">Slovak Republic</option><option value="SI">Slovenia</option><option value="SB">Solomon Islands</option><option value="SO">Somalia</option><option value="ZA">South Africa</option><option value="GS">South Georgia</option><option value="KR">South Korea</option><option value="ES">Spain</option><option value="LK">Sri Lanka</option><option value="SD">Sudan</option><option value="SR">Suriname</option><option value="SJ">Svalbard and Jan Mayen Islands</option><option value="SZ">Swaziland</option><option value="SE">Sweden</option><option value="CH">Switzerland</option><option value="SY">Syrian Arab Republic</option><option value="TW">Taiwan</option><option value="TJ">Tajikistan</option><option value="TZ">Tanzania</option><option value="TG">Togo</option><option value="TK">Tokelau</option><option value="TO">Tonga</option><option value="TH">Thailand</option><option value="TT">Trinidad and Tobago</option><option value="TN">Tunisia</option><option value="TR">Turkey</option><option value="TM">Turkmenistan</option><option value="TC">Turks and Caicos Islands</option><option value="TV">Tuvalu</option><option value="UG">Uganda</option><option value="UA">Ukraine</option><option value="AE">United Arab Emirates</option><option value="UY">Uruguay</option><option value="UM">US Minor Outlying Islands</option><option value="UZ">Uzbekistan</option><option value="VU">Vanuatu</option><option value="VE">Venezuela</option><option value="VN">Vietnam</option><option value="VG">Virgin Islands (British)</option><option value="VI">Virgin Islands (USA)</option><option value="WF">Wallis and Futuna Islands</option><option value="EH">Western Sahara</option><option value="WS">Western Samoa</option><option value="YE">Yemen</option><option value="YU">Yugoslavia</option><option value="ZM">Zambia</option><option value="ZW">Zimbabwe</option> </select>
  259. </p>
  260.  
  261. <p id="give-card-state-wrap" class="form-row form-row-last form-row-responsive">
  262. <label for="card_state" class="give-label">
  263. State / Province <span class="give-required-indicator">*</span>
  264. <span class="give-tooltip give-icon give-icon-question"
  265. data-tooltip="The state or province for your billing address."></span>
  266. </label>
  267.  
  268. <select
  269. name="card_state"
  270. id="card_state"
  271. class="card_state give-select required"
  272. required aria-required="true" >
  273. <option value="" selected='selected'></option><option value="AL">Alabama</option><option value="AK">Alaska</option><option value="AZ">Arizona</option><option value="AR">Arkansas</option><option value="CA">California</option><option value="CO">Colorado</option><option value="CT">Connecticut</option><option value="DE">Delaware</option><option value="DC">District of Columbia</option><option value="FL">Florida</option><option value="GA">Georgia</option><option value="HI">Hawaii</option><option value="ID">Idaho</option><option value="IL">Illinois</option><option value="IN">Indiana</option><option value="IA">Iowa</option><option value="KS">Kansas</option><option value="KY">Kentucky</option><option value="LA">Louisiana</option><option value="ME">Maine</option><option value="MD">Maryland</option><option value="MA">Massachusetts</option><option value="MI">Michigan</option><option value="MN">Minnesota</option><option value="MS">Mississippi</option><option value="MO">Missouri</option><option value="MT">Montana</option><option value="NE">Nebraska</option><option value="NV">Nevada</option><option value="NH">New Hampshire</option><option value="NJ">New Jersey</option><option value="NM">New Mexico</option><option value="NY">New York</option><option value="NC">North Carolina</option><option value="ND">North Dakota</option><option value="OH">Ohio</option><option value="OK">Oklahoma</option><option value="OR">Oregon</option><option value="PA">Pennsylvania</option><option value="RI">Rhode Island</option><option value="SC">South Carolina</option><option value="SD">South Dakota</option><option value="TN">Tennessee</option><option value="TX">Texas</option><option value="UT">Utah</option><option value="VT">Vermont</option><option value="VA">Virginia</option><option value="WA">Washington</option><option value="WV">West Virginia</option><option value="WI">Wisconsin</option><option value="WY">Wyoming</option><option value="AS">American Samoa</option><option value="CZ">Canal Zone</option><option value="CM">Commonwealth of the Northern Mariana Islands</option><option value="FM">Federated States of Micronesia</option><option value="GU">Guam</option><option value="MH">Marshall Islands</option><option value="MP">Northern Mariana Islands</option><option value="PW">Palau</option><option value="PI">Philippine Islands</option><option value="PR">Puerto Rico</option><option value="TT">Trust Territory of the Pacific Islands</option><option value="VI">Virgin Islands</option><option value="AA">Armed Forces - Americas</option><option value="AE">Armed Forces - Europe, Canada, Middle East, Africa</option><option value="AP">Armed Forces - Pacific</option> </select>
  274. </p>
  275. </fieldset>
  276. <div id="give-twocheckout-errors"></div> <fieldset id="give_purchase_submit">
  277. <p id="give-final-total-wrap" class="form-wrap ">
  278. <span
  279. class="give-donation-total-label">Donation Total:</span>
  280. <span class="give-final-total-amount"
  281. data-total="10.00">$10.00</span>
  282. </p>
  283. <input type="hidden" name="give-user-id" value="1"/>
  284. <input type="hidden" name="give_action" value="purchase"/>
  285. <input type="hidden" name="give-gateway" value="twocheckout"/>
  286. <div class="give-submit-button-wrap give-clearfix">
  287. <input type="submit" class="give-submit give-btn" id="give-purchase-button" name="give-purchase"
  288. value="Donate Now"/>
  289. <span class="give-loading-animation"></span>
  290. </div>
  291. </fieldset>
  292.  
  293. </div>
  294.  
  295. </form>
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