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="JPY" />
   </html>{{{SupportLevel}}}<html>
   

   <select name="a3">
     <option value="3600"></html>{{{Tier}}} 0 (¥3600/{{{year}}})<html></option>
     <option value="6000" selected="selected"></html>{{{Tier}}} 1 (¥6000/{{{year}}})<html></option>
     <option value="13200"></html>{{{Tier}}} 2 (¥13200/{{{year}}}<html></option>
     <option value="24000"></html>{{{Tier}}} 3 (¥24000/{{{year}}})<html> </option>
     <option value="48000"></html>{{{Tier}}} 4 (¥48000/{{{year}}})<html> </option>
   <option value="72000"></html>{{{Tier}}} 5 (¥72000/{{{year}}})<html> </option>
   <option value="132000"></html>{{{Tier}}} 6 (¥132000/{{{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>