%%TEMPLATE:adminheader%%
%%TEMPLATE:adminheader_payment%%

<center>
<font color="#333333" size="2" face="Verdana"><b>
Charge An Account:
</b></font></center>

<center>
<form action=subscribe.cgi method=get target=_blank>
<input type=hidden name=action value=charge>
<input type=hidden name=login value="%%login%%">
<input type=hidden name="cc_last_digits" value="%%cc last digits%%">
<input type=hidden name="cc_expiration" value="%%cc expiration%%">

<table border=0>
<tr>
    <td><font size=2 face=verdana>Login</font></td>
    <td>%%login%%</td>
</tr>
<tr>
    <td><font size=2 face=verdana>Payment Type</font></td>
    <td><select name=payment>%%payment options%%</select></td>
</tr>
<tr>
    <td><font size=2 face=verdana>Credit Card No</font></td>
    <td>**** **** **** %%cc last digits%%</select></td>
</tr>
<tr>
    <td><font size=2 face=verdana>Credit Card Expiration </font></td>
    <td>%%cc expiration%%</select></td>
</tr>
</table>

<input type=submit name=submit value=" Update  ">
</form>
</center>
<p>

%%TEMPLATE:adminfooter%%