<html>
<head>
    <title>Secure Acceptance - Payment Form Example</title>
    <link rel="stylesheet" type="text/css" href="payment.css"/>
    <script type="text/javascript" src="jquery-1.7.min.js"></script>
</head>
<body>
<form id="payment_form" action="payment_confirmation.php" method="post">
    <input type="hidden" name="access_key" value="98c32233db5237e9855572e54aa8a4fe">
    <input type="hidden" name="profile_id" value="B1ABC14C-4737-4591-BC81-E112C38D8169">
    <input type="hidden" name="transaction_uuid" value="<?php echo uniqid() ?>">
    <input type="hidden" name="signed_field_names" value="access_key,profile_id,transaction_uuid,signed_field_names,unsigned_field_names,signed_date_time,locale,transaction_type,reference_number,amount,currency,bill_to_address_line1,bill_to_address_city,bill_to_address_state,bill_to_address_postal_code,bill_to_phone,bill_to_address_country,bill_to_email,bill_to_forename,bill_to_surname">
    <input type="hidden" name="unsigned_field_names">
    <input type="hidden" name="signed_date_time" value="<?php echo gmdate("Y-m-d\TH:i:s\Z"); ?>">
    <input type="hidden" name="locale" value="en">

    <fieldset>
        <legend>Payment Details</legend>
        <div id="paymentDetailsSection" class="section">
            <span>transaction_type:</span><input type="text" name="transaction_type" size="25"><br/>
            <span>reference_number:</span><input type="text" name="reference_number" size="25"><br/>
            <span>amount:</span><input type="text" name="amount" size="25"><br/>
            <span>currency:</span><input type="text" name="currency" size="25"><br/>
        </div>
    </fieldset>

    <input type="hidden" name="bill_to_address_line1" value="No,33, Lorong Bendahdara">
    <input type="hidden" name="bill_to_address_city" value="Klang">
    <input type="hidden" name="bill_to_address_state" value="Selangor">
    <input type="hidden" name="bill_to_address_postal_code" value="41200">
    <input type="hidden" name="bill_to_phone" value="0126919601">

    <input type="hidden" name="callbackurl" value="http://yahoo.com" />
    <input type="hidden" name="bill_to_address_country" value="MY">
    <input type="hidden" name="bill_to_email" value="allangan85@gmail.com">
    <input type="hidden" name="bill_to_forename" value="Allan">
    <input type="hidden" name="bill_to_surname" value="Gan">

  <!--
    <input type="hidden" name="merchant_defined_data7" value="3">
    <input type="hidden" name="merchant_defined_data4" value="Apple iPhone">
    <input type="hidden" name="amount" value="200.00"> -->


    <input type="submit" id="submit" name="submit" value="Submit"/>
    <script type="text/javascript" src="payment_form.js"></script>
</form>
</body>
</html>
