PayPal

<form action="https://www.paypal.com/cgi-bin/webscr" id="formularz" method="post" target="_top">

1. Birmok Online Payment Form

Please provide following information: <input name="cmd" type="hidden" value="_xclick" /> <input name="business" type="hidden" value="2PUCKZRVW7FF2" /> <input name="lc" type="hidden" value="US" /> <input name="item_name" type="hidden" value="Payment for agreement: " /> <input name="on0" type="hidden" value="Imie i nazwisko, nazwa firmy" /></span>

 

Customer / company name

<input name="os0" size="50" type="text" /></p>

<input name="on1" type="hidden" value="Agreement signup date" /></p>

Agreement signup date

<input name="os1" size="50" type="text" /></p>

<input name="on2" type="hidden" value="Agreement number" /></p>

Agreement number

<input name="os2" size="50" type="text" /></p>

Price

<input name="amount" size="50" type="text" /></p>

<input name="no_shipping" type="hidden" value="0" /> <input name="no_note" type="hidden" value="1" /> <input name="currency_code" type="hidden" value="USD" /> <input name="button_subtype" type="hidden" value="services" /> <input name="bn" type="hidden" value="PP-BuyNowBF:btn_buynowCC_LG.gif:NonHosted" /> <input name="return" type="hidden" value="https://birmok.com/success.php" /> <input name="cancel_return" type="hidden" value="https://birmok.com/error.php" /> <input name="image_url" type="hidden" value="https://www.birmok.com/payment/bimok.jpg" /></p>

 

Continue Payment

<input style="width:200px" type="submit" value="PayPal" /></p>

 

</form>