User:Suisui/Sandbox

<html>

 <form class="contrib" action="https://www.paypal.com/</html>{{{PayPalLang}}}<html>cgi-bin/webscr" method="post">
   <input type="hidden" name="business" value="donation@wikipedia.org" />
   <input type="hidden" name="item_name" value="</html>{{{YearlyDonation}}}<html>" />
   <input type="hidden" name="item_number" value="DONATE" />
   <input type="hidden" name="no_note" value="0" />
   <input type="hidden" name="currency_code" value="USD" />
   </html>{{{SupportLevel}}}<html>
   

   <select name="a3">
     <option value="30.00"></html>{{{Tier}}} 0 ($30/{{{year}}})<html></option>
     <option value="60.00" selected="selected"></html>{{{Tier}}} 1 ($60/{{{year}}})<html></option>
     <option value="120.00"></html>{{{Tier}}} 2 ($120/{{{year}}})<html></option>
     <option value="240.00"></html>{{{Tier}}} 3 ($240/{{{year}}})<html> </option>
     <option value="420.00"></html>{{{Tier}}} 4 ($420/{{{year}}})<html> </option>
   <option value="600.00"></html>{{{Tier}}} 5 ($600/{{{year}}})<html> </option>
   <option value="1200.00"></html>{{{Tier}}} 6 ($1200/{{{year}}})<html> </option>
   </select>
   <input type="hidden" name="cmd" value="_xclick-subscriptions" />
  <input type="hidden" name="p3" value="1" />
   <input type="hidden" name="t3" value="Y" />
   <input type="hidden" name="src" value="1" />
   <input type="hidden" name="sra" value="1" />
   <input type="hidden" name="on0" value="Comment" />
   <input type="hidden" name="on1" value="Anonymity" />
   


   </html>{{{ShortComment}}}<html>*

   <input type="text" name="os0" maxlength="200" />

</html>{{{MentionName}}}<html>*

<input type="radio" name="os1" value="Mention my name"></html>{{{Yes}}}<html>
<input type="radio" name="os1" value="Don't mention my name"></html>{{{No}}}<html>

</html>{{{IfNo}}}<html>

*</html>{{{Optional}}}<html>

   <input class="centered" type="submit" value="</html>{{{Submit}}}<html>" />
 </form>

</html>