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POST payment_confirmation.php

<form id="dataFrm" action="payment_confirmation.php" method="post" enctype="multipart/form-data" autocomplete="off" novalidate="novalidate">
  <div class="wpr__amount">
    <!-- <input type="text" required="required" class="txtAmount txtStyle" maxlength="6" name="txtAmount" value="50" > -->
    <div class="TextInput formElement ContactForm-Text">
      <input class="txtAmount TextInput-field formElement-field ty-b2 formElement-field--filled" type="text" maxlength="6" value="0" id="txtAmount" name="txtAmount" placeholder="Amount*" required="required" aria-required="true">
      <label class="formElement-label ty-c4" for="txtAmount">Amount*</label>
      <span class="usd__sign">USD $</span>
    </div>
  </div>
  <!-- <input type="text" required="required" class="txtFirstName txtStyle" name="txtFirstName" maxlength="50" value="" placeholder="Firt name *"> -->
  <div class="TextInput formElement ContactForm-Text">
    <input class="txtFirstName TextInput-field formElement-field ty-b2" type="text" maxlength="20" value="" id="txtFirstName" name="txtFirstName" placeholder="First name*" required="required" aria-required="true">
    <label class="formElement-label ty-c4" for="txtFirstName">First name*</label>
  </div>
  <!-- <input type="text" required="required" class="txtLastName txtStyle" name="txtLastName" maxlength="50" value="" placeholder="Last name *"><br /> -->
  <div class="TextInput formElement ContactForm-Text">
    <input class="txtLastName TextInput-field formElement-field ty-b2" type="text" maxlength="20" value="" id="txtLastName" name="txtLastName" placeholder="Last name*" required="required" aria-required="true">
    <label class="formElement-label ty-c4" for="txtLastName">Last name*</label>
  </div>
  <!-- <input type="text" required="required" class="txtPhone txtStyle" name="txtPhone" maxlength="13" value="" placeholder="Phone number *"><br /> -->
  <div class="TextInput formElement ContactForm-Text">
    <input class="txtPhone TextInput-field formElement-field ty-b2" type="text" maxlength="13" value="" id="txtPhone" name="txtPhone" placeholder="Phone number*" required="required" aria-required="true">
    <label class="formElement-label ty-c4" for="txtPhone">Phone number*</label>
  </div>
  <!-- <input type="email" required="required" class="txtEmail txtStyle" name="txtEmail" maxlength="50" value="" placeholder="Email address *"><br /> -->
  <div class="TextInput formElement ContactForm-Text">
    <input class="txtEmail TextInput-field formElement-field ty-b2" type="email" maxlength="50" value="" id="txtEmail" name="txtEmail" placeholder="Email address*" required="required" aria-required="true">
    <label class="formElement-label ty-c4" for="txtEmail">Email address*</label>
  </div>
  <div class="TextInput formElement ContactForm-Text">
    <select name="txtCountry" id="txtCountry" class="Dropdown-field formElement-field ty-b2" required="required" aria-required="true">
      <option selected="" value="">Country*</option>
      <option value="Afghanistan">Afghanistan</option>
      <option value="Albania">Albania</option>
      <option value="Algeria">Algeria</option>
      <option value="American Samoa">American Samoa</option>
      <option value="Andorra">Andorra</option>
      <option value="Angola">Angola</option>
      <option value="Anguilla">Anguilla</option>
      <option value="Antartica">Antarctica</option>
      <option value="Antigua and Barbuda">Antigua and Barbuda</option>
      <option value="Argentina">Argentina</option>
      <option value="Armenia">Armenia</option>
      <option value="Aruba">Aruba</option>
      <option value="Australia">Australia</option>
      <option value="Austria">Austria</option>
      <option value="Azerbaijan">Azerbaijan</option>
      <option value="Bahamas">Bahamas</option>
      <option value="Bahrain">Bahrain</option>
      <option value="Bangladesh">Bangladesh</option>
      <option value="Barbados">Barbados</option>
      <option value="Belarus">Belarus</option>
      <option value="Belgium">Belgium</option>
      <option value="Belize">Belize</option>
      <option value="Benin">Benin</option>
      <option value="Bermuda">Bermuda</option>
      <option value="Bhutan">Bhutan</option>
      <option value="Bolivia">Bolivia</option>
      <option value="Bosnia and Herzegowina">Bosnia and Herzegowina</option>
      <option value="Botswana">Botswana</option>
      <option value="Bouvet Island">Bouvet Island</option>
      <option value="Brazil">Brazil</option>
      <option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
      <option value="Brunei Darussalam">Brunei Darussalam</option>
      <option value="Bulgaria">Bulgaria</option>
      <option value="Burkina Faso">Burkina Faso</option>
      <option value="Burundi">Burundi</option>
      <option value="Cambodia">Cambodia</option>
      <option value="Cameroon">Cameroon</option>
      <option value="Canada">Canada</option>
      <option value="Cape Verde">Cape Verde</option>
      <option value="Cayman Islands">Cayman Islands</option>
      <option value="Central African Republic">Central African Republic</option>
      <option value="Chad">Chad</option>
      <option value="Chile">Chile</option>
      <option value="China">China</option>
      <option value="Christmas Island">Christmas Island</option>
      <option value="Cocos Islands">Cocos (Keeling) Islands</option>
      <option value="Colombia">Colombia</option>
      <option value="Comoros">Comoros</option>
      <option value="Congo">Congo</option>
      <option value="Congo">Congo, the Democratic Republic of the</option>
      <option value="Cook Islands">Cook Islands</option>
      <option value="Costa Rica">Costa Rica</option>
      <option value="Cota D'Ivoire">Cote d'Ivoire</option>
      <option value="Croatia">Croatia (Hrvatska)</option>
      <option value="Cuba">Cuba</option>
      <option value="Cyprus">Cyprus</option>
      <option value="Czech Republic">Czech Republic</option>
      <option value="Denmark">Denmark</option>
      <option value="Djibouti">Djibouti</option>
      <option value="Dominica">Dominica</option>
      <option value="Dominican Republic">Dominican Republic</option>
      <option value="East Timor">East Timor</option>
      <option value="Ecuador">Ecuador</option>
      <option value="Egypt">Egypt</option>
      <option value="El Salvador">El Salvador</option>
      <option value="Equatorial Guinea">Equatorial Guinea</option>
      <option value="Eritrea">Eritrea</option>
      <option value="Estonia">Estonia</option>
      <option value="Ethiopia">Ethiopia</option>
      <option value="Falkland Islands">Falkland Islands (Malvinas)</option>
      <option value="Faroe Islands">Faroe Islands</option>
      <option value="Fiji">Fiji</option>
      <option value="Finland">Finland</option>
      <option value="France">France</option>
      <option value="France Metropolitan">France, Metropolitan</option>
      <option value="French Guiana">French Guiana</option>
      <option value="French Polynesia">French Polynesia</option>
      <option value="French Southern Territories">French Southern Territories</option>
      <option value="Gabon">Gabon</option>
      <option value="Gambia">Gambia</option>
      <option value="Georgia">Georgia</option>
      <option value="Germany">Germany</option>
      <option value="Ghana">Ghana</option>
      <option value="Gibraltar">Gibraltar</option>
      <option value="Greece">Greece</option>
      <option value="Greenland">Greenland</option>
      <option value="Grenada">Grenada</option>
      <option value="Guadeloupe">Guadeloupe</option>
      <option value="Guam">Guam</option>
      <option value="Guatemala">Guatemala</option>
      <option value="Guinea">Guinea</option>
      <option value="Guinea-Bissau">Guinea-Bissau</option>
      <option value="Guyana">Guyana</option>
      <option value="Haiti">Haiti</option>
      <option value="Heard and McDonald Islands">Heard and Mc Donald Islands</option>
      <option value="Holy See">Holy See (Vatican City State)</option>
      <option value="Honduras">Honduras</option>
      <option value="Hong Kong">Hong Kong</option>
      <option value="Hungary">Hungary</option>
      <option value="Iceland">Iceland</option>
      <option value="India">India</option>
      <option value="Indonesia">Indonesia</option>
      <option value="Iran">Iran (Islamic Republic of)</option>
      <option value="Iraq">Iraq</option>
      <option value="Ireland">Ireland</option>
      <option value="Israel">Israel</option>
      <option value="Italy">Italy</option>
      <option value="Jamaica">Jamaica</option>
      <option value="Japan">Japan</option>
      <option value="Jordan">Jordan</option>
      <option value="Kazakhstan">Kazakhstan</option>
      <option value="Kenya">Kenya</option>
      <option value="Kiribati">Kiribati</option>
      <option value="Democratic People's Republic of Korea">Korea, Democratic People's Republic of</option>
      <option value="Korea">Korea, Republic of</option>
      <option value="Kuwait">Kuwait</option>
      <option value="Kyrgyzstan">Kyrgyzstan</option>
      <option value="Lao">Lao People's Democratic Republic</option>
      <option value="Latvia">Latvia</option>
      <option value="Lebanon">Lebanon</option>
      <option value="Lesotho">Lesotho</option>
      <option value="Liberia">Liberia</option>
      <option value="Libyan Arab Jamahiriya">Libyan Arab Jamahiriya</option>
      <option value="Liechtenstein">Liechtenstein</option>
      <option value="Lithuania">Lithuania</option>
      <option value="Luxembourg">Luxembourg</option>
      <option value="Macau">Macau</option>
      <option value="Macedonia">Macedonia, The Former Yugoslav Republic of</option>
      <option value="Madagascar">Madagascar</option>
      <option value="Malawi">Malawi</option>
      <option value="Malaysia">Malaysia</option>
      <option value="Maldives">Maldives</option>
      <option value="Mali">Mali</option>
      <option value="Malta">Malta</option>
      <option value="Marshall Islands">Marshall Islands</option>
      <option value="Martinique">Martinique</option>
      <option value="Mauritania">Mauritania</option>
      <option value="Mauritius">Mauritius</option>
      <option value="Mayotte">Mayotte</option>
      <option value="Mexico">Mexico</option>
      <option value="Micronesia">Micronesia, Federated States of</option>
      <option value="Moldova">Moldova, Republic of</option>
      <option value="Monaco">Monaco</option>
      <option value="Mongolia">Mongolia</option>
      <option value="Montserrat">Montserrat</option>
      <option value="Morocco">Morocco</option>
      <option value="Mozambique">Mozambique</option>
      <option value="Myanmar">Myanmar</option>
      <option value="Namibia">Namibia</option>
      <option value="Nauru">Nauru</option>
      <option value="Nepal">Nepal</option>
      <option value="Netherlands">Netherlands</option>
      <option value="Netherlands Antilles">Netherlands Antilles</option>
      <option value="New Caledonia">New Caledonia</option>
      <option value="New Zealand">New Zealand</option>
      <option value="Nicaragua">Nicaragua</option>
      <option value="Niger">Niger</option>
      <option value="Nigeria">Nigeria</option>
      <option value="Niue">Niue</option>
      <option value="Norfolk Island">Norfolk Island</option>
      <option value="Northern Mariana Islands">Northern Mariana Islands</option>
      <option value="Norway">Norway</option>
      <option value="Oman">Oman</option>
      <option value="Pakistan">Pakistan</option>
      <option value="Palau">Palau</option>
      <option value="Panama">Panama</option>
      <option value="Papua New Guinea">Papua New Guinea</option>
      <option value="Paraguay">Paraguay</option>
      <option value="Peru">Peru</option>
      <option value="Philippines">Philippines</option>
      <option value="Pitcairn">Pitcairn</option>
      <option value="Poland">Poland</option>
      <option value="Portugal">Portugal</option>
      <option value="Puerto Rico">Puerto Rico</option>
      <option value="Qatar">Qatar</option>
      <option value="Reunion">Reunion</option>
      <option value="Romania">Romania</option>
      <option value="Russia">Russian Federation</option>
      <option value="Rwanda">Rwanda</option>
      <option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
      <option value="Saint LUCIA">Saint LUCIA</option>
      <option value="Saint Vincent">Saint Vincent and the Grenadines</option>
      <option value="Samoa">Samoa</option>
      <option value="San Marino">San Marino</option>
      <option value="Sao Tome and Principe">Sao Tome and Principe</option>
      <option value="Saudi Arabia">Saudi Arabia</option>
      <option value="Senegal">Senegal</option>
      <option value="Seychelles">Seychelles</option>
      <option value="Sierra">Sierra Leone</option>
      <option value="Singapore">Singapore</option>
      <option value="Slovakia">Slovakia (Slovak Republic)</option>
      <option value="Slovenia">Slovenia</option>
      <option value="Solomon Islands">Solomon Islands</option>
      <option value="Somalia">Somalia</option>
      <option value="South Africa">South Africa</option>
      <option value="South Georgia">South Georgia and the South Sandwich Islands</option>
      <option value="Span">Spain</option>
      <option value="SriLanka">Sri Lanka</option>
      <option value="St. Helena">St. Helena</option>
      <option value="St. Pierre and Miguelon">St. Pierre and Miquelon</option>
      <option value="Sudan">Sudan</option>
      <option value="Suriname">Suriname</option>
      <option value="Svalbard">Svalbard and Jan Mayen Islands</option>
      <option value="Swaziland">Swaziland</option>
      <option value="Sweden">Sweden</option>
      <option value="Switzerland">Switzerland</option>
      <option value="Syria">Syrian Arab Republic</option>
      <option value="Taiwan">Taiwan, Province of China</option>
      <option value="Tajikistan">Tajikistan</option>
      <option value="Tanzania">Tanzania, United Republic of</option>
      <option value="Thailand">Thailand</option>
      <option value="Togo">Togo</option>
      <option value="Tokelau">Tokelau</option>
      <option value="Tonga">Tonga</option>
      <option value="Trinidad and Tobago">Trinidad and Tobago</option>
      <option value="Tunisia">Tunisia</option>
      <option value="Turkey">Turkey</option>
      <option value="Turkmenistan">Turkmenistan</option>
      <option value="Turks and Caicos">Turks and Caicos Islands</option>
      <option value="Tuvalu">Tuvalu</option>
      <option value="Uganda">Uganda</option>
      <option value="Ukraine">Ukraine</option>
      <option value="United Arab Emirates">United Arab Emirates</option>
      <option value="United Kingdom">United Kingdom</option>
      <option value="United States">United States</option>
      <option value="United States Minor Outlying Islands">United States Minor Outlying Islands</option>
      <option value="Uruguay">Uruguay</option>
      <option value="Uzbekistan">Uzbekistan</option>
      <option value="Vanuatu">Vanuatu</option>
      <option value="Venezuela">Venezuela</option>
      <option value="Vietnam">Viet Nam</option>
      <option value="Virgin Islands (British)">Virgin Islands (British)</option>
      <option value="Virgin Islands (U.S)">Virgin Islands (U.S.)</option>
      <option value="Wallis and Futana Islands">Wallis and Futuna Islands</option>
      <option value="Western Sahara">Western Sahara</option>
      <option value="Yemen">Yemen</option>
      <option value="Yugoslavia">Yugoslavia</option>
      <option value="Zambia">Zambia</option>
      <option value="Zimbabwe">Zimbabwe</option>
    </select>
    <label class="formElement-label formElement--focusAlways ty-c4" for="txtCountry">Country*</label>
  </div>
  <div class="TextInput formElement ContactForm-Text">
    <textarea name="txtPurpose" class="txtPurpose TextareaField-field formElement-field ty-b2" id="txtPurpose" rows="4" cols="50" maxlength="127" placeholder="Description" required="required" aria-required="true"></textarea>
    <label class="formElement-label formElement--focusAlways ty-c4" for="txtPurpose">Description*</label>
  </div>
  <div class="_row">
    <div class="wrapper_choice_buttons">
      <div class="spit_choice_buttons">
        <input type="radio" name="payment_option" id="cards" checked="" value="cards" require="required">
        <label class="paymentOption option option-1" for="cards">
          <div class="dot"></div>
          <img class="cardType" src="asset/ic_generic_3x.png">
          <span class="detailCard001"> Credit/Debit Card<img class="bundleCard" src="asset/4Cards_3x.png">
          </span>
        </label>
        <input type="radio" name="payment_option" id="abapay_khqr" value="abapay_khqr" require="required">
        <label class="paymentOption option option-2" for="abapay_khqr">
          <div class="dot"></div>
          <img class="cardType" src="asset/ABA_KHQR_4x.png">
          <span class="detailCard002">
            <span class="titleCard">ABA KHQR</span>
            <span class="detailCard003">Scan to pay with any banking app</span>
          </span>
        </label>
      </div>
    </div>
  </div>
  <div class="spacing30"><!--SPACING--></div>
  <input type="submit" class="ZbtnDonate actionBtn-gateway margin-l0" value="Process to Donate">
</form>

Text Content

MAKE A DONATION
HUSK CAMBODIA

Please be informed only $500 allowed per transaction due to our bank policy.
If you wish to donate more than $500, multiple transactions required. Our
apologies for this inconvenience caused.


Amount* USD $
First name*
Last name*
Phone number*
Email address*
Country* Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla
Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria
Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin
Bermuda Bhutan Bolivia Bosnia and Herzegowina Botswana Bouvet Island Brazil
British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi
Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad
Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo
Congo, the Democratic Republic of the Cook Islands Costa Rica Cote d'Ivoire
Croatia (Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica
Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea
Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland
France France, Metropolitan French Guiana French Polynesia French Southern
Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland
Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and Mc
Donald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland
India Indonesia Iran (Islamic Republic of) Iraq Ireland Israel Italy Jamaica
Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of
Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia
Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania
Luxembourg Macau Macedonia, The Former Yugoslav Republic of Madagascar Malawi
Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius
Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco
Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands
Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue
Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua
New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar
Reunion Romania Russian Federation Rwanda Saint Kitts and Nevis Saint LUCIA
Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi
Arabia Senegal Seychelles Sierra Leone Singapore Slovakia (Slovak Republic)
Slovenia Solomon Islands Somalia South Africa South Georgia and the South
Sandwich Islands Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan
Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab
Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of
Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan
Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United
Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan
Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis
and Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe Country*
Description*

Credit/Debit Card

ABA KHQR Scan to pay with any banking app

powered by: ©HUSK Cambodia