<form action="https://www.paypal.com/cgi-bin/webscr" method="post" target="_top">
<input type="hidden" name="cmd" value="_s-xclick">
<input type="hidden" name="hosted_button_id" value="6PBSMFQY4EAR8">
<table>
<tr><td><input type="hidden" name="on0" value="Premium access list:">Premium access list:</td></tr><tr><td><select name="os0">
	<option value="1 Month Access">1 Month Access €5.50 EUR</option>
	<option value="1 Month Access">1 Month Access €12.50 EUR</option>
	<option value="1 Month Access">1 Month Access €20.50 EUR</option>
</select> </td></tr>
<tr><td><input type="hidden" name="on1" value="Enter Your Nickname.">Enter Your Nickname.</td></tr><tr><td><input type="text" name="os1" maxlength="200"></td></tr>
</table>
<input type="hidden" name="currency_code" value="EUR">
<input type="image" src="https://www.paypalobjects.com/en_US/i/btn/btn_paynowCC_LG.gif" border="0" name="submit" alt="PayPal - The safer, easier way to pay online!">
<img alt="" border="0" src="https://www.paypalobjects.com/en_US/i/scr/pixel.gif" width="1" height="1">
</form>