<input type=”hidden” name=”on0″ value=”Donation Amount”>;
Donation Amount:

<select name=”os0″>;
<option value=”Option 1″>;Option 1 $5.00</option>;
<option value=”Option 2″>;Option 2 $15.00</option>;
<option value=”Option 3″>;Option 3 $25.00</option>;
<option value=”Option 4″>;Option 4 $50.00</option>;
<option value=”Option 5″>;Option 5 $75.00</option>;
<option value=”Option 6″>;Option 6 $100.00</option>;
<option value=”Option 7″>;Option 7 $250.00</option>;
<option value=”Option 8″>;Option 8 $500.00</option>;
<option value=”Option 9″>;Option 9 $1,000.00</option>;
</select>;

<input type=”hidden” name=”on1″ value=”Comments”>;
Comments:

<input type=”text” name=”os1″ maxlength=”200″>;
<input type=”hidden” name=”no_note” value=”0″>;</td>

;</tr>

;

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