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<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="/img/donate-md.png" type="image" style="width: auto" alt="BitPay, the easy way to pay with bitcoins." border="0">\\
</div>\\
</fieldset>\\
</form> //
//
