<form action="https://www.paypal.com/cgi-bin/webscr" method="post">
<input type="hidden" name="cmd" value="_xclick-subscriptions">
<input type="hidden" name="business" value="cmansr@cattanis.com">
<input type="hidden" name="lc" value="US">
<input type="hidden" name="item_name" value="dfgdfghdfgdfgfd">
<input type="hidden" name="no_note" value="1">
<input type="hidden" name="a3" value="100.00">
<input type="hidden" name="currency_code" value="USD">
<input type="hidden" name="src" value="1">
<input type="hidden" name="p3" value="4">
<input type="hidden" name="t3" value="M">
<input type="hidden" name="srt" value="4">
<input type="hidden" name="sra" value="1">
<input type="hidden" name="bn" value="PP-SubscriptionsBF:btn_subscribeCC_LG.gif:NonHostedGuest">
<table>
<tr><td><input type="hidden" name="on0" value="dfgfdgdfgdfg">dfgfdgdfgdfg</td></tr><tr><td><input type="text" name="os0" maxlength="60"></td></tr>
</table>
<input type="image" src="https://www.paypal.com/en_US/i/btn/btn_subscribeCC_LG.gif" border="0" name="submit" alt="PayPal - The safer, easier way to pay online!">
<img alt="" border="0" src="https://www.paypal.com/en_US/i/scr/pixel.gif" width="1" height="1">
</form>