<form id="makeDonation" action="https://bitpay.com/checkout" method="post" onsubmit="return bp.validateMobileCheckoutForm($('#makeDonation'));">
        <input name="action" type="hidden" value="checkout">
        <fieldset class="phone-form well form-horizontal" style="margin-top: 5px;">
          <ul>
            <li id="orderID" class="control-group">
              <label class="control-label" style="width: 40px">Email:</label>
              <div class="controls" style="margin-left: 60px">
                <input name="orderID" type="email" class="input input-xlarge" placeholder="Email address (optional)" maxlength=50 autocapitalize=off autocorrect=off><br>
              </div>
            </li>
            <li id="price" class="control-group">
              <label class="control-label" style="width: 40px">Amount:</label>
              <div class="controls" style="margin-left: 60px">
                <input name="price" type="number" class="noscroll" value="10.00" placeholder="Amount" maxlength="10" min="0.01" step="0.01" style="width: 39%"  />
                <select name="currency" value="" style="width: 49%" >
                  <option value="USD" selected="selected">USD</option>
                  <option value="BTC">BTC</option>
                  <option value="EUR">EUR</option>
                  <option value="GBP">GBP</option>
                  <option value="AUD">AUD</option>
                  <option value="BGN">BGN</option>
                  <option value="BRL">BRL</option>
                  <option value="CAD">CAD</option>
                  <option value="CHF">CHF</option>
                  <option value="CNY">CNY</option>
                  <option value="CZK">CZK</option>
                  <option value="DKK">DKK</option>
                  <option value="HKD">HKD</option>
                  <option value="HRK">HRK</option>
                  <option value="HUF">HUF</option>
                  <option value="IDR">IDR</option>
                  <option value="ILS">ILS</option>
                  <option value="INR">INR</option>
                  <option value="JPY">JPY</option>
                  <option value="KRW">KRW</option>
                  <option value="LTL">LTL</option>
                  <option value="LVL">LVL</option>
                  <option value="MXN">MXN</option>
                  <option value="MYR">MYR</option>
                  <option value="NOK">NOK</option>
                  <option value="NZD">NZD</option>
                  <option value="PHP">PHP</option>
                  <option value="PLN">PLN</option>
                  <option value="RON">RON</option>
                  <option value="RUB">RUB</option>
                  <option value="SEK">SEK</option>
                  <option value="SGD">SGD</option>
                  <option value="THB">THB</option>
                  <option value="TRY">TRY</option>
                  <option value="ZAR">ZAR</option>
                </select/>
              </div>
            </li>
          </ul>
          <br>
          <input type="hidden" name="data" value="Uwp0Uo6LFockGEc45BMcr10HSBU1zd96SX+jdE2MMQNuGB7kymOCuqOCMwT6YBhS+G97VRbWp2yWeZItp/97qfdZgIwl1J3ehsIIp/3paupcmmt70eQPNR0aZDxIr7TTgAMwElx0FJYladMHRWWdOmk1jtJQFGcDTmFwytmvZ5DtfeV3B4PoQi3jlL0CVqNLcBFku4wu+jG8SVLi7ALpR5qPqiZaoC0YC6GoMBFlw0o=">
          <div style="margin: auto; width: 100%; text-align: center">
            <input name="submit" src="_media/img/donate-md.png" type="image" style="width: auto" alt="BitPay, the easy way to pay with bitcoins." border="0">
          </div>
        </fieldset>
      </form>