Secure credit card payment form for veggiedate ad

Secure Credit card payment for a VeggieDate gift membership.

Gift membership level:

(Optional) recipient's ad number:	(if known)
Credit card billing information
Full name appearing on credit card:
billing Street Address:
billing City:
billing State:
billing Country:
billing Postal code/ zipcode:
Card Number:	(1111222233334444)
Expiration:
CVV2:	(rightmost 3 digits on back/ amex 4 on front)
Email receipt to:
If you are a paid member & want the holiday promo, be sure the email address above corresponds to the one in your account or include your ad number below.
(Optional) Your ad number:
	Add the two numbers: + = (required to stop form spam)
(Click Once! processing takes up to 20 seconds)