Below is just a sample of html
FORM action="" method="POST" enctype="" name="ccform" onsubmit="return validateCard(this.cardNumber.value,this.cardType.value,this.cardMonth.value,this.cardYear.value);">
<TABLE cellspacing="5" cellpadding="2" bgcolor="#DA9D67">
<TR>
<TD align="right" valign="middle" nowrap><P>Select Card Type:</P></TD>
<TD valign="bottom" nowrap>
<SELECT name="cardType">
<OPTION value="a"> American Express
<OPTION value="d"> Discover
<OPTION value="m"> MasterCard
<OPTION value="v"> Visa
</SELECT>
</TD>
</TR>
<TR>
<TD align="right" valign="middle" nowrap><P>Enter Card Number:</P></TD>
<TD valign="bottom" nowrap>
<P><INPUT type="Text" name="cardNumber" size="17" maxlength="16"> example: <FONT size=-1><I>( 1234567890123456 )</I></I></FONT></P>
</TD>
</TR>
<TR>
<TD align="right" valign="middle" nowrap><P>Select Expiration Date:</P></TD>
<TD valign="bottom" nowrap>
<P>
<SELECT name="cardMonth">
<OPTION value="01"> 01
<OPTION value="02"> 02
<OPTION value="03"> 03
<OPTION value="04"> 04
<OPTION value="05"> 05
<OPTION value="06"> 06
<OPTION value="07"> 07
<OPTION value="08"> 08
<OPTION value="09"> 09
<OPTION value="10"> 10
<OPTION value="11"> 11
<OPTION value="12"> 12
</SELECT>
<SELECT name="cardYear">
<OPTION value="1999"> 99
<OPTION value="2000"> 00
<OPTION value="2001"> 01
<OPTION value="2002"> 02
<OPTION value="2003"> 03
<OPTION value="2004"> 04
<OPTION value="2005"> 05
<OPTION value="2006"> 06
<OPTION value="2007"> 07
<OPTION value="2008"> 08
<OPTION value="2009"> 09
<OPTION value="2010"> 10
</SELECT>
example: <FONT size=-1><I>( MM YY )</I></I></FONT>
</P>
</TD>
</TR>
<TR>
<TD colspan="2" align="CENTER">
<INPUT type="Submit" name="submit" value="Submit"> <INPUT type="reset" value="Reset">
</TD>
</TR>
</TABLE>
</FORM>
</BODY>
