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				<p><img alt="Week of Compassion" src="/uploads/wysiwyg/1369/images/woc_logo.gif" style="width: 720px; height: 100px; margin: 0px auto 20px; " />
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<p><strong>Thank you for your online contribution to Week of Compassion. Your gift enables us - together - to offer help and hope to hurting people around the world, around the year. No gift is too small!</strong>
</p>
<p>WOC currently responds to some kind of disaster or emergency somewhere in the world on average of approximately once every one and a half days. Recent major disasters receive much of our attention and resources. At the same time, we continue to respond to other grave humanitarian tragedies. The Global Food Crisis is impacting more and more countries and reversing the modest gains that had been made in recent years against hunger, and has now become one of our most pressing priorities.
</p>
<p>Your gifts to the Compassion Response Fund and to &#39;Where Most Needed&#39; enable us to respond immediately to disasters and emergencies - &#39;big&#39; or &#39;small&#39; - as they arise. Designated donations enable us to continue supporting the work of our church partners who continue to respond under some of the most difficult and dangerous circumstances imaginable.
</p>
<p><strong>As you make your gift, please consider joining the growing number of WOC friends who are now making recurring gifts monthly or quarterly, thereby strengthening WOC&#39;s witness and work in the world day in and day out.</strong>
</p>
<p><em>3% of your gift will go toward credit card processing fees. We encourage you to add 3% to your gift to allow more funds to go directly toward ministry. Thank you.</em>
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<p class="EditRecurring"><strong>Do you need to edit your recurring gift?</strong> Login using the link at the top of this page, go to your &quot;account dashboard&quot; and click on &quot;Subscriptions.&quot;
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<p><span class="required">* indicates a required field</span>
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<hr />
<p>
	<label for="gift_amount" class="label">Gift Amount:</label>
	<span class="field_vert">
	<input name="gift_amount" type="radio" value="50" id="amount.647724.50" />
	<label for="amount.647724.50">$50</label> <br />
	<input name="gift_amount" type="radio" value="100" id="amount.647724.100" />
	<label for="amount.647724.100">$100</label> <br />
	<input name="gift_amount" type="radio" value="500" id="amount.647724.500" />
	<label for="amount.647724.500">$500</label> <br />
	<input name="gift_amount" type="radio" value="1000" id="amount.647724.1000" />
	<label for="amount.647724.1000">$1000</label> <br />
	<input name="gift_amount" type="radio" value="other" id="amount.647724.other" />
	<label for="amount.647724.other">Other</label> <br /><br />
	$ <input name="gift_amount" type="text" value="" id="gift_amount" size="10" onkeypress="return numbers_only(event, true);" />
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	<input name="_amount_647724" type="radio" value="1004988" id="radio.647724.3" />
	<label for="radio.647724.3">Quarterly Gift</label>
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	<input name="_amount_647724" type="radio" value="1004989" id="radio.647724.4" />
	<label for="radio.647724.4">Annual Gift</label>
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<p style="margin:0 0 5px 255px;">If you you are a member of a Christian Church (Disciples of Christ) congregation, please provide the name and location of your congregation below:
</p>
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</p>
<p>
	<label for="congregation" class="label">Congregation Name, City, State:</label>
	<input name="congregation" type="text" value="" id="congregation" size="35" maxlength="100" />
</p>
<h2>Gift Designation</h2>
<p>Please indicate where you would like your gift to be directed.
</p>
<p>
	<label for="designation" class="label">Designation <span class="required">*</span></label>
	<span class="field_vert">
	<input name="designation" type="radio" value="1886024" id="radio.647749.1" />
	<label for="radio.647749.1" id="choice.1886024">Hurricane Relief</label>
	<br />
	<input name="designation" type="radio" value="1004996" id="radio.647749.2" />
	<label for="radio.647749.2" id="choice.1004996">Syria Humanitarian Crisis</label>
	<br />
	<input name="designation" type="radio" value="1851036" id="radio.647749.3" />
	<label for="radio.647749.3" id="choice.1851036">Famine</label>
	<br />
	<input name="designation" type="radio" value="1540191" id="radio.647749.4" />
	<label for="radio.647749.4" id="choice.1540191">Earthquake</label>
	<br />
	<input name="designation" type="radio" value="1004994" id="radio.647749.5" />
	<label for="radio.647749.5" id="choice.1004994">Where Most Needed</label>
	<br />
	<input name="designation" type="radio" value="1335461" id="radio.647749.6" />
	<label for="radio.647749.6" id="choice.1335461">Refugees</label>
	<br />
	<input name="designation" type="radio" value="1004995" id="radio.647749.7" />
	<label for="radio.647749.7" id="choice.1004995">US Storms and Fires</label>
	<br />
	<input name="designation" type="radio" value="1004998" id="radio.647749.8" />
	<label for="radio.647749.8" id="choice.1004998">Women's Empowerment Fund</label>
	<br />
	<input name="designation" type="radio" value="1004999" id="radio.647749.9" />
	<label for="radio.647749.9" id="choice.1004999">Sustainable Development</label>
	<br />
	<input name="designation" type="radio" value="1005000" id="radio.647749.10" />
	<label for="radio.647749.10" id="choice.1005000">Endowment (please indicate below)</label>
	</span>
</p>
<p>If you would like to contribute to an established named endowment fund, please type the name of the fund below. Otherwise, your gift will be directed to the General Week of Compassion Endowment Fund.
</p>
<p>
	<label for="named_endowment_fund" class="label">Named Endowment Fund:</label>
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</p>
<h2>Dedication</h2>
<p>
	<label for="type_of_dedication" class="label">Type of dedication:</label>
	<span class="field_vert">
	<input name="type_of_dedication" type="radio" value="1004990" id="radio.647730.1" />
	<label for="radio.647730.1" id="choice.1004990">on behalf of</label>
	<br />
	<input name="type_of_dedication" type="radio" value="1004991" id="radio.647730.2" />
	<label for="radio.647730.2" id="choice.1004991">in honor of</label>
	<br />
	<input name="type_of_dedication" type="radio" value="1004992" id="radio.647730.3" />
	<label for="radio.647730.3" id="choice.1004992">in memory of</label>
	</span>
</p>
<p>
	<label for="dedication" class="label">Dedication:</label>
	<input name="dedication" type="text" value="" id="dedication" size="35" maxlength="100" />
</p>
<p>Please send an acknowledgement to whom I am dedicating my donation.
</p>
<p>
	<label for="via_email_address" class="label">via email address:</label>
	<input name="via_email_address" type="text" value="" id="via_email_address" size="35" maxlength="100" />
</p>
<p>or</p>
<p>
	<label for="usmail" class="label">via U.S. mail:</label>
	<textarea name="usmail" id="usmail" cols="50" rows="3" maxlength="" /></textarea>
</p>
<h2>Contact Information</h2>
<p>
	<label for="first_name" class="label">First Name: <span class="required">*</span></label>
	<input name="first_name" type="text" value="" id="first_name" size="20" maxlength="100" />
</p>
<p>
	<label for="last_name" class="label">Last Name: <span class="required">*</span></label>
	<input name="last_name" type="text" value="" id="last_name" size="20" maxlength="100" />
</p>
<p>
	<label for="address" class="label">Address <span class="required">*</span></label>
	<input name="address" type="text" value="" id="address" size="40" maxlength="100" />
</p>
<p>
	<label for="city" class="label">City: <span class="required">*</span></label>
	<input name="city" type="text" value="" id="city" size="20" maxlength="100" />
</p>
<p>
	<label for="state" class="label">State:</label>
	<select name="state" id="state">
		<option value="" selected="selected">- SELECT -</option>
		<option value="AA">AF Americas</option>
		<option value="AE">AF Europe</option>
		<option value="AK">Alaska</option>
		<option value="AL">Alabama</option>
		<option value="AP">AF Pacific</option>
		<option value="AR">Arkansas</option>
		<option value="AZ">Arizona</option>
		<option value="CA">California</option>
		<option value="CO">Colorado</option>
		<option value="CT">Connecticut</option>
		<option value="DC">District of Columbia</option>
		<option value="DE">Delaware</option>
		<option value="FL">Florida</option>
		<option value="GA">Georgia</option>
		<option value="GU">Guam</option>
		<option value="HI">Hawaii</option>
		<option value="IA">Iowa</option>
		<option value="ID">Idaho</option>
		<option value="IL">Illinois</option>
		<option value="IN">Indiana</option>
		<option value="KS">Kansas</option>
		<option value="KY">Kentucky</option>
		<option value="LA">Louisiana</option>
		<option value="MA">Massachusetts</option>
		<option value="MD">Maryland</option>
		<option value="ME">Maine</option>
		<option value="MI">Michigan</option>
		<option value="MN">Minnesota</option>
		<option value="MO">Missouri</option>
		<option value="MS">Mississippi</option>
		<option value="MT">Montana</option>
		<option value="NC">North Carolina</option>
		<option value="ND">North Dakota</option>
		<option value="NE">Nebraska</option>
		<option value="NH">New Hampshire</option>
		<option value="NJ">New Jersey</option>
		<option value="NM">New Mexico</option>
		<option value="NV">Nevada</option>
		<option value="NY">New York</option>
		<option value="OH">Ohio</option>
		<option value="OK">Oklahoma</option>
		<option value="OR">Oregon</option>
		<option value="PA">Pennsylvania</option>
		<option value="PR">Puerto Rico</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="VA">Virginia</option>
		<option value="VT">Vermont</option>
		<option value="WA">Washington</option>
		<option value="WI">Wisconsin</option>
		<option value="WV">West Virginia</option>
		<option value="WY">Wyoming</option>
	</select>
</p>
<p>
	<label for="zip_code" class="label">Zip Code: <span class="required">*</span></label>
	<input name="zip_code" type="text" value="" id="zip_code" size="20" maxlength="100" />
</p>
<p>
	<label for="country" class="label">Country</label>
	<select name="country" id="country">
		<option value="">- SELECT -</option>
		<option value="AF">Afghanistan</option>
		<option value="AX">Aland Islands</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 Darussalam</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="CA">Canada</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 (Keeling) Islands</option>
		<option value="CO">Colombia</option>
		<option value="KM">Comoros</option>
		<option value="CG">Congo (Brazzaville)</option>
		<option value="CD">Congo (Kinshasa)</option>
		<option value="CK">Cook Islands</option>
		<option value="CR">Costa Rica</option>
		<option value="CI">Cote D'Ivoire</option>
		<option value="HR">Croatia</option>
		<option value="CU">Cuba</option>
		<option value="CY">Cyprus</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="EC">Ecuador</option>
		<option value="EG">Egypt</option>
		<option value="SV">El Salvador</option>
		<option value="GQ">Equatorial Guinea</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="GH">Ghana</option>
		<option value="GI">Gibraltar</option>
		<option value="GR">Greece</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 Island and Mcdonald Islands</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">Laos</option>
		<option value="LV">Latvia</option>
		<option value="LB">Lebanon</option>
		<option value="LS">Lesotho</option>
		<option value="LR">Liberia</option>
		<option value="LY">Libya</option>
		<option value="LI">Liechtenstein</option>
		<option value="LT">Lithuania</option>
		<option value="LU">Luxembourg</option>
		<option value="MO">Macao</option>
		<option value="MK">Macedonia, Republic of</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</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">Philippines</option>
		<option value="PN">Pitcairn</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</option>
		<option value="RO">Romania</option>
		<option value="RU">Russian Federation</option>
		<option value="RW">Rwanda</option>
		<option value="BL">Saint Barthelemy</option>
		<option value="SH">Saint Helena</option>
		<option value="KN">Saint Kitts and Nevis</option>
		<option value="LC">Saint Lucia</option>
		<option value="MF">Saint Martin</option>
		<option value="PM">Saint Pierre and Miquelon</option>
		<option value="VC">Saint Vincent and the Grenadines</option>
		<option value="WS">Samoa</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">Slovakia</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</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, United Republic of</option>
		<option value="TH">Thailand</option>
		<option value="TL">Timor-Leste</option>
		<option value="TG">Togo</option>
		<option value="TK">Tokelau</option>
		<option value="TO">Tonga</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="GB">United Kingdom</option>
		<option value="US" selected="selected">United States</option>
		<option value="UM">United States Minor Outlying Islands</option>
		<option value="UY">Uruguay</option>
		<option value="UZ">Uzbekistan</option>
		<option value="VU">Vanuatu</option>
		<option value="VA">Vatican City</option>
		<option value="VE">Venezuela</option>
		<option value="VN">Viet Nam</option>
		<option value="VG">Virgin Islands, British</option>
		<option value="VI">Virgin Islands, U.S.</option>
		<option value="WF">Wallis and Futuna</option>
		<option value="EH">Western Sahara</option>
		<option value="YE">Yemen</option>
		<option value="ZM">Zambia</option>
		<option value="ZW">Zimbabwe</option>
	</select>
</p>
<p>
	<label for="email_address" class="label">Email Address: <span class="required">*</span></label>
	<input name="email_address" type="text" value="" id="email_address" size="30" />
</p>
<p>
	<label for="_email_address" class="label">Confirm Email: <span class="required">*</span></label>
	<input name="_email_address" type="text" value="" id="_email_address" size="30" />
</p>
<p>
	<label class="label">&nbsp;</label>
	<input type="hidden" name="emailupdates" value="0" />
	<input name="emailupdates" type="checkbox" value="1" id="emailupdates" />
	<label for="emailupdates">Check box to subscribe to email updates</label>
	<span id="check.2177538">&nbsp;</span>
	<abbr class="help" title="By providing your email you agree to receive periodic emails from Week of Compassion.">help?</abbr>
</p>
<p>
	<label for="phone" class="label">Phone: <span class="required">*</span></label>
	<input name="phone[0]" type="text" value="" id="phone" size="3" maxlength="3" /> -
	<input name="phone[1]" type="text" size="3" maxlength="3" /> -
	<input name="phone[2]" type="text" size="4" maxlength="4" />
</p>
<br />
<p>
	<input name="_account_create" type="checkbox" value="1" id="_account_create" />
	<label for="_account_create">Create an account.</label>
	<a href="#why" onclick="return toggle_login_why(true);">Why create an account?</a>
</p>
<div id="_account_fields" class="indent">
	<p>
		<label for="_account_username" class="label">Username</label>
		<span class="field_vert">
		<input name="_account_username" type="text" value="" id="_account_username" size="20" />
		</span>
	</p>
	<p>
		<label for="_account_password" class="label">Password</label>
		<input name="_account_password" type="password" value="" id="_account_password" />
	</p>
	<p>
		<label for="_account_confpass" class="label">Confirm Password</label>
		<input name="_account_confpass" type="password" value="" id="_account_confpass" />
	</p>
	<p>Already have an account? Click <a href="#login" onclick="return toggle_login(true);">here</a> to login.</p>
</div>
<script type="text/javascript">
	selectize('input[name="_account_create"]', 1, 'div#_account_fields');
</script>
<div id="login_main" style="display: none;">
	<div id="login_shade">&nbsp;</div>
	<div id="login_wrap">
		<div id="login_close"><a href="#close" onclick="return toggle_login(false);">Close [X]</a></div>				
		<div id="login_box">
			<h1>Account Login</h1>
			<div id="login_fields">
				<p class="username_now">
					<label for="_login_username" class="label_m">Username</label>
					<input name="_login_username" type="text" id="_login_username" />
				</p>
				<p class="password_row">
					<label for="_login_password" class="label_m">Password</label>
					<span class="field_vert">
						<input name="_login_password" type="password" id="_login_password" /><br />
						<a href="/forgotpass" class="forgot_password">Forgot password?</a>
					</span>
				</p>
				<p class="redirect_row"><input name="_login_redirect" type="checkbox" value="1" id="_login_redirect" /> <label for="_login_redirect">After login go to dashboard</label></p>
			</div>
			<p class="center_align button_row">
				<input name="_login_flag" type="hidden" value="0" id="_login_flag" />
				<input name="cmd=update" type="submit" value="Login" class="button key" />
			</p>
		</div>
		<div id="login_why" style="display: none;">
			<h1>Why create an account?</h1>
			<p>Creating an account will allow you to save your donor information and edit your recurring gift after your initial gift is made. Account creation is easy and secure!</p>
		</div>
	</div>
</div>
<h2>Billing Information</h2>
<p>Please click the link &quot;(Copy address information from above)&quot; if your billing address is the same as your contact address. (Next to Payment method option below)
</p>
<div id="billing.wrapper" style="">
<p>
	<label class="label_payment">Payment Method</label>
	<span class="field_vert">
		<input type="hidden" name="_billing_647744" id="_billing_647744" class="_billing_total" value="0" />
		<input name="_billing_method" type="radio" value="7970" checked="checked" class="!empty($g['jwt'])" id="_billing_method_7970" />
		<label for="_billing_method_7970"> Credit Card</label>&nbsp;&nbsp;
		<span id="_copy_above" style="display: none;">
			(<a href="#">Copy address information from above</a>)
		</span>
	</span>
</p>
<div id="billing.fields">
	<p class="label">
		<label for="_billing_first_name" class="label">First Name <span class="required">*</span></label>
		<input name="_billing_first_name" type="text" value="" id="_billing_first_name" size="20" maxlength="25" />
	</p>
	<p class="label">
		<label for="_billing_last_name" class="label">Last Name <span class="required">*</span></label>
		<input name="_billing_last_name" type="text" value="" id="_billing_last_name" size="20" maxlength="25" />
	</p>
	<p class="label">
		<label for="_billing_card_type" class="label">Card Type <span class="required">*</span></label>
		<select name="_billing_card_type" id="_billing_card_type">
			<option value="" selected="selected">Select Type:</option>
			<option value="visa">Visa</option>
			<option value="mast">MasterCard</option>
			<option value="amex">American Express</option>
			<option value="disc">Discover Card</option>
		</select>
	</p>
	<p class="label">
		<label for="_billing_card_number" class="label">Card Number <span class="required">*</span></label>
		<input name="_billing_card_number" type="text" value="" id="_billing_card_number" maxlength="16" onkeypress="return numbers_only(event);" />
	</p>
	<p class="label">
		<label for="_billing_expires_m" class="label">Expiration Date <span class="required">*</span></label>		
		<select name="_billing_expires[m]" id="_billing_expires_m">
			<option value="" selected="selected">Month:</option>
			<option value="01">1 - January</option><option value="02">2 - February</option><option value="03">3 - March</option><option value="04">4 - April</option><option value="05">5 - May</option><option value="06">6 - June</option><option value="07">7 - July</option><option value="08">8 - August</option><option value="09">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option>
		</select>
		<select name="_billing_expires[y]" id="_billing_expires_y">
			<option value="" selected="selected">Year:</option>
			<option value="2018">2018</option><option value="2019">2019</option><option value="2020">2020</option><option value="2021">2021</option><option value="2022">2022</option><option value="2023">2023</option><option value="2024">2024</option><option value="2025">2025</option><option value="2026">2026</option><option value="2027">2027</option><option value="2028">2028</option><option value="2029">2029</option><option value="2030">2030</option><option value="2031">2031</option><option value="2032">2032</option><option value="2033">2033</option>
		</select>
	</p>
	<p class="label">
		<label for="_billing_cvv2" class="label">Security Code <span class="required">*</span></label>
		<input name="_billing_cvv2" type="text" value="" id="_billing_cvv2" maxlength="4" size="4" onkeypress="return numbers_only(event);" />
		<img src="/images/mini_cvv2.gif" width="51" height="31" class="valign_top" alt="CVV2" />
	</p>
	<p class="label">
		<label for="_billing_address" class="label">Address <span class="required">*</span></label>
		<input name="_billing_address" type="text" value="" id="_billing_address" size="25" maxlength="75" />
	</p>
	<p class="label">
		<label for="_billing_city" class="label">City <span class="required">*</span></label>
		<input name="_billing_city" type="text" value="" id="_billing_city" size="25" maxlength="25" />
	</p>
	<p class="label">
		<label for="_billing_country" class="label">Country <span class="required">*</span></label>
		<select name="_billing_country" id="_billing_country">
			<option value="">Select Country:</option>
			<option value="AF">Afghanistan</option><option value="AX">Aland Islands</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 Darussalam</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="CA">Canada</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 (Keeling) Islands</option><option value="CO">Colombia</option><option value="KM">Comoros</option><option value="CG">Congo (Brazzaville)</option><option value="CD">Congo (Kinshasa)</option><option value="CK">Cook Islands</option><option value="CR">Costa Rica</option><option value="CI">Cote D'Ivoire</option><option value="HR">Croatia</option><option value="CU">Cuba</option><option value="CY">Cyprus</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="EC">Ecuador</option><option value="EG">Egypt</option><option value="SV">El Salvador</option><option value="GQ">Equatorial Guinea</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="GH">Ghana</option><option value="GI">Gibraltar</option><option value="GR">Greece</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 Island and Mcdonald Islands</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">Laos</option><option value="LV">Latvia</option><option value="LB">Lebanon</option><option value="LS">Lesotho</option><option value="LR">Liberia</option><option value="LY">Libya</option><option value="LI">Liechtenstein</option><option value="LT">Lithuania</option><option value="LU">Luxembourg</option><option value="MO">Macao</option><option value="MK">Macedonia, Republic of</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</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">Philippines</option><option value="PN">Pitcairn</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</option><option value="RO">Romania</option><option value="RU">Russian Federation</option><option value="RW">Rwanda</option><option value="BL">Saint Barthelemy</option><option value="SH">Saint Helena</option><option value="KN">Saint Kitts and Nevis</option><option value="LC">Saint Lucia</option><option value="MF">Saint Martin</option><option value="PM">Saint Pierre and Miquelon</option><option value="VC">Saint Vincent and the Grenadines</option><option value="WS">Samoa</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">Slovakia</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</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, United Republic of</option><option value="TH">Thailand</option><option value="TL">Timor-Leste</option><option value="TG">Togo</option><option value="TK">Tokelau</option><option value="TO">Tonga</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="GB">United Kingdom</option><option value="US" selected="selected">United States</option><option value="UM">United States Minor Outlying Islands</option><option value="UY">Uruguay</option><option value="UZ">Uzbekistan</option><option value="VU">Vanuatu</option><option value="VA">Vatican City</option><option value="VE">Venezuela</option><option value="VN">Viet Nam</option><option value="VG">Virgin Islands, British</option><option value="VI">Virgin Islands, U.S.</option><option value="WF">Wallis and Futuna</option><option value="EH">Western Sahara</option><option value="YE">Yemen</option><option value="ZM">Zambia</option><option value="ZW">Zimbabwe</option>
		</select>
	</p>
	<p class="label" id="_billing_state_row">
		<label for="_billing_state" class="label">State <span class="required">*</span></label>
		<select name="_billing_state" id="_billing_state">
			<option value="" selected="selected">Select State:</option>
			<option value="AA">AF Americas</option><option value="AE">AF Europe</option><option value="AK">Alaska</option><option value="AL">Alabama</option><option value="AP">AF Pacific</option><option value="AR">Arkansas</option><option value="AZ">Arizona</option><option value="CA">California</option><option value="CO">Colorado</option><option value="CT">Connecticut</option><option value="DC">District of Columbia</option><option value="DE">Delaware</option><option value="FL">Florida</option><option value="GA">Georgia</option><option value="GU">Guam</option><option value="HI">Hawaii</option><option value="IA">Iowa</option><option value="ID">Idaho</option><option value="IL">Illinois</option><option value="IN">Indiana</option><option value="KS">Kansas</option><option value="KY">Kentucky</option><option value="LA">Louisiana</option><option value="MA">Massachusetts</option><option value="MD">Maryland</option><option value="ME">Maine</option><option value="MI">Michigan</option><option value="MN">Minnesota</option><option value="MO">Missouri</option><option value="MS">Mississippi</option><option value="MT">Montana</option><option value="NC">North Carolina</option><option value="ND">North Dakota</option><option value="NE">Nebraska</option><option value="NH">New Hampshire</option><option value="NJ">New Jersey</option><option value="NM">New Mexico</option><option value="NV">Nevada</option><option value="NY">New York</option><option value="OH">Ohio</option><option value="OK">Oklahoma</option><option value="OR">Oregon</option><option value="PA">Pennsylvania</option><option value="PR">Puerto Rico</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="VA">Virginia</option><option value="VT">Vermont</option><option value="WA">Washington</option><option value="WI">Wisconsin</option><option value="WV">West Virginia</option><option value="WY">Wyoming</option>
		</select>
	</p>
	<p class="label" id="_billing_province_row">
		<label for="_billing_province" class="label">State/Province</label>
		<input name="_billing_province" type="text" value="" id="_billing_province" size="25" maxlength="25" />
	</p>
	<script type="text/javascript">
		country_state('_billing_country', '_billing_state', '_billing_state_row', '_billing_province_row');
	</script>
	<p class="label">
		<label for="_billing_zip_code" class="label">Zip/Postal Code <span class="required">*</span></label>
		<input name="_billing_zip_code" type="text" value="" id="_billing_zip_code" size="20" maxlength="15" />
	</p>
</div>
</div>
<p class="total">
	<label class="label">Total Gift:</label> <span id="total.647754">$0.00</span>
</p>
<p class="submit_row">
	<span>
		<input name="cmd=forward" type="submit" value="Submit My Gift" class="button_forward" />
	</span>
</p>
<p class="post_submit_row" style="display:none;">
	<span>
		<img src="/images/ajax2.gif" />
	</span>
	 Submitting, Please Wait...
</p>
				

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