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<input type="hidden" name="cmd" value="_s-xclick">
<input type="hidden" name="hosted_button_id" value="TYMHEKB2ZYNCA">
<table>
<tr><td><input type="hidden" name="on0" value="desc">desc</td></tr><tr><tr><td>Select the maximum amount you want to pay each month</td></tr><td>$<select name="os0">
    <option value="10.00"> 10.00</option>
    <option value="20.00"> 20.00</option>
    <option value="30.00"> 30.00</option>
    <option value="40.00"> 40.00</option>
    <option value="55.00"> 55.00</option>
    <option value="65.00"> 65.00</option>
</select> USD</td></tr>
</table>
<table>
</table>
<table><tr><td align=center><i>Sign up for</i></td></tr><tr><td><input type="image" src="https://www.paypalobjects.com/en_US/i/btn/btn_auto_billing_CC_LG.gif" border="0" name="submit" alt="PayPal - The safer, easier way to pay online!"></td></tr></table>
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