<form id="makeDonation" action="https:bitpay.com/checkout" method="post" onsubmit="return bp.validateMobileCheckoutForm($('#makeDonation'));">\\ 
<input name="action" type="hidden" value="checkout">\\ 
<fieldset class="phone-form well form-horizontal" style="margin-top: 5px;">\\ 
<ul>\\ 
<li id="orderID" class="control-group">\\ 
<label class="control-label" style="width: 40px">Email:</label>\\ 
<div class="controls" style="margin-left: 60px">\\ 
<input name="orderID" type="email" class="input input-xlarge" placeholder="Email address (optional)" maxlength=50 autocapitalize=off autocorrect=off><br>\\ 
</div>\\ 
</li>\\ 
<li id="price" class="control-group">\\ 
<label class="control-label" style="width: 40px">Amount:</label>\\ 
<div class="controls" style="margin-left: 60px">\\ 
<input name="price" type="number" class="noscroll" value="10.00" placeholder="Amount" maxlength="10" min="0.01" step="0.01" style="width: 39%" />\\ 
<select name="currency" value="" style="width: 49%" >\\ 
<option value="USD" selected="selected">USD</option>\\ 
<option value="BTC">BTC</option>\\ 
<option value="EUR">EUR</option>\\ 
<option value="GBP">GBP</option>\\ 
<option value="AUD">AUD</option>\\ 
<option value="BGN">BGN</option>\\ 
<option value="BRL">BRL</option>\\ 
<option value="CAD">CAD</option>\\ 
<option value="CHF">CHF</option>\\ 
<option value="CNY">CNY</option>\\ 
<option value="CZK">CZK</option>\\ 
<option value="DKK">DKK</option>\\ 
<option value="HKD">HKD</option>\\ 
<option value="HRK">HRK</option>\\ 
<option value="HUF">HUF</option>\\ 
<option value="IDR">IDR</option>\\ 
<option value="ILS">ILS</option>\\ 
<option value="INR">INR</option>\\ 
<option value="JPY">JPY</option>\\ 
<option value="KRW">KRW</option>\\ 
<option value="LTL">LTL</option>\\ 
<option value="LVL">LVL</option>\\ 
<option value="MXN">MXN</option>\\ 
<option value="MYR">MYR</option>\\ 
<option value="NOK">NOK</option>\\ 
<option value="NZD">NZD</option>\\ 
<option value="PHP">PHP</option>\\ 
<option value="PLN">PLN</option>\\ 
<option value="RON">RON</option>\\ 
<option value="RUB">RUB</option>\\ 
<option value="SEK">SEK</option>\\ 
<option value="SGD">SGD</option>\\ 
<option value="THB">THB</option>\\ 
<option value="TRY">TRY</option>\\ 
<option value="ZAR">ZAR</option>\\ 
</select/>\\ 
</div>\\ 
</li>\\ 
</ul>\\ 
<br>\\ 
<input type="hidden" name="data" value="Uwp0Uo6LFockGEc45BMcr10HSBU1zd96SX+jdE2MMQNuGB7kymOCuqOCMwT6YBhS+G97VRbWp2yWeZItp/97qfdZgIwl1J3ehsIIp/3paupcmmt70eQPNR0aZDxIr7TTgAMwElx0FJYladMHRWWdOmk1jtJQFGcDTmFwytmvZ5DtfeV3B4PoQi3jlL0CVqNLcBFku4wu+jG8SVLi7ALpR5qPqiZaoC0YC6GoMBFlw0o=">\\ 
<div style="margin: auto; width: 100%; text-align: center">\\ 
<input name="submit" src="/img/donate-md.png" type="image" style="width: auto" alt="BitPay, the easy way to pay with bitcoins." border="0">\\ 
</div>\\ 
</fieldset>\\ 
</form>