<form name="mainform" class="mainform" action="https://secure.bluepay.com/interfaces/bp10emu" method="POST">
<input type="hidden" name="MERCHANT" value="100331905289">
<input type="hidden" name="DBA" value="Armed Forces Benefit Assoc">
<input type="hidden" name="TRANSACTION_TYPE" value="AUTH">
<input type="hidden" name="TAMPER_PROOF_SEAL" value="643606cd94550fa0cbf9cbaaa2e867ba">
<input type="hidden" name="APPROVED_URL" value="https://secure.bluepay.com/interfaces/shpf?SHPF_FORM_ID=AF5STG02&SHPF_ACCOUNT_ID=100331905289&SHPF_TPS_DEF=SHPF%5FACCOUNT%5FID%20SHPF%5FFORM%5FID%20RETURN%5FURL%20DBA%20AMEX%5FIMAGE%20DISCOVER%5FIMAGE%20SHPF%5FTPS%5FDEF&SHPF_TPS=059260d0b2b932fd9cb9338deb930bad&RETURN_URL=javascript%3A%20window%2Ehistory%2Ego%28%2D1%29&DBA=Armed%20Forces%20Benefit%20Assoc&AMEX_IMAGE=spacer%2Egif&DISCOVER_IMAGE=spacer%2Egif">
<input type="hidden" name="DECLINED_URL" value="https://secure.bluepay.com/interfaces/shpf?SHPF_FORM_ID=AF5STG02&SHPF_ACCOUNT_ID=100331905289&SHPF_TPS_DEF=SHPF%5FACCOUNT%5FID%20SHPF%5FFORM%5FID%20RETURN%5FURL%20DBA%20AMEX%5FIMAGE%20DISCOVER%5FIMAGE%20SHPF%5FTPS%5FDEF&SHPF_TPS=059260d0b2b932fd9cb9338deb930bad&RETURN_URL=javascript%3A%20window%2Ehistory%2Ego%28%2D1%29&DBA=Armed%20Forces%20Benefit%20Assoc&AMEX_IMAGE=spacer%2Egif&DISCOVER_IMAGE=spacer%2Egif">
<input type="hidden" name="MISSING_URL" value="https://secure.bluepay.com/interfaces/shpf?SHPF_FORM_ID=AF5STG02&SHPF_ACCOUNT_ID=100331905289&SHPF_TPS_DEF=SHPF%5FACCOUNT%5FID%20SHPF%5FFORM%5FID%20RETURN%5FURL%20DBA%20AMEX%5FIMAGE%20DISCOVER%5FIMAGE%20SHPF%5FTPS%5FDEF&SHPF_TPS=059260d0b2b932fd9cb9338deb930bad&RETURN_URL=javascript%3A%20window%2Ehistory%2Ego%28%2D1%29&DBA=Armed%20Forces%20Benefit%20Assoc&AMEX_IMAGE=spacer%2Egif&DISCOVER_IMAGE=spacer%2Egif">
<input type="hidden" name="CUSTOM_ID" value="">
<input type="hidden" name="CUSTOM_ID2" value="">
<input type="hidden" name="ORDER_ID" value="">
<input type="hidden" name="INVOICE_ID" value="">
<input type="hidden" name="COMMENT" value="">
<input type="hidden" name="MODE" value="LIVE">
<input type="hidden" name="REBILLING" value="0">
<input type="hidden" name="REB_CYCLES" value="">
<input type="hidden" name="REB_AMOUNT" value="">
<input type="hidden" name="REB_EXPR" value="">
<input type="hidden" name="REB_FIRST_DATE" value="">
<input type="hidden" name="TPS_DEF" value="MERCHANT APPROVED_URL DECLINED_URL MISSING_URL MODE TRANSACTION_TYPE TPS_DEF AMOUNT REBILLING REB_CYCLES REB_AMOUNT REB_EXPR REB_FIRST_DATE">
<input type="hidden" name="MERCHDATA_shpf-form-id" value="AF5STG01">
<input type="hidden" name="RESPONSEVERSION" value="">
<input type="hidden" name="RESPONSETYPE" value="">
<input type="hidden" name="RESPONSE_TITLE" value="">
<input type="hidden" name="RESPONSE_BODY" value="">
<input type="hidden" name="BP_STAMP_DEF" value="">
<input type="hidden" name="AMOUNT" value="0.00">
<legend class="block">Payment Info</legend>
<div class="block-01-push">
<div class="icons vi-mc" data-credit-card-type></div>
<label for="CC_NUM">Credit Card Number</label>
<input type="text" name="CC_NUM" id="CC_NUM" class="required creditcard" value="" autocomplete="cc-number">
<label for="CC_EXPIRES">Expiration Date</label>
<select name="CC_EXPIRES_MONTH" id="CC_EXPIRES" class="required" autocomplete="cc-exp-month">
<option value="" selected>Month</option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<div class="select-error-01"></div>
<select name="CC_EXPIRES_YEAR" class="required" autocomplete="cc-exp-year">
<option value="" selected>Year</option>
<option value="17">2017</option><option value="18">2018</option><option value="19">2019</option><option value="20">2020</option><option value="21">2021</option><option value="22">2022</option><option value="23">2023</option><option value="24">2024</option><option value="25">2025</option><option value="26">2026</option>
<div class="select-error-02"></div>
<legend class="block">Billing Contact Info</legend>
<label for="NAME">Name</label>
<input type="text" name="NAME" id="NAME" class="required" value="" autocomplete="cc-name">
<label for="ZIPCODE">Postal Code</label>
<input type="text" name="ZIPCODE" id="ZIPCODE" class="required" value="" size="7" autocomplete="no">
<div class="block-01-push">
<input type="submit" class="button--primary" value="Generate Token">
<input type="reset" value="Reset" class="button">