Donate

<div class="et_pb_contact"><!-- [et_pb_line_break_holder] --> <form class="et_pb_contact_form clearfix" name="customerData" method="post" action="https://www.forumforautism.org/pg/ccavRequestHandler.php"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --><p class="et_pb_contact_field et_pb_contact_field_0 et_pb_contact_field_half"><!-- [et_pb_line_break_holder] --><span class="dn-hd">Donation Amount in INR</span><!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><input type="hidden" name="tid" id="tid" readonly /><!-- [et_pb_line_break_holder] --><input type="hidden" name="merchant_id" value="76230"/><!-- [et_pb_line_break_holder] --><input type="hidden" name="order_id" id="oid" /><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><p class="et_pb_contact_field et_pb_contact_field_1 et_pb_contact_field_half et_pb_contact_field_last"><!-- [et_pb_line_break_holder] --><label for="amount" class="et_pb_contact_form_label">Amount</label><!-- [et_pb_line_break_holder] --><input type="number" class="input" name="amount" type="number" min="1000" max="1000000" step="1000" pattern="[0-9]{4,6}" placeholder="Amount" required><!-- [et_pb_line_break_holder] --><!-- <input type="text" name="amount" id="amount" value="1.00"> --><!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><input type="hidden" name="currency" value="INR"/><!-- [et_pb_line_break_holder] --><input type="hidden" name="redirect_url" value="https://www.forumforautism.org/transaction-response.php"/><!-- [et_pb_line_break_holder] --><input type="hidden" name="cancel_url" value="https://www.forumforautism.org/transaction-response.php"/><!-- [et_pb_line_break_holder] --><input type="hidden" name="language" value="EN"/><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><p class="et_pb_contact_field et_pb_contact_field_4 et_pb_contact_field_last"><!-- [et_pb_line_break_holder] --><label for="billing_name" class="et_pb_contact_form_label">Full Name</label><!-- [et_pb_line_break_holder] --><input type="text" id="billing_name" class="input" name="billing_name" data-field_type="input" pattern="[a-zA-Z ]{3,}" title="Enter Valid Full Name" data-original_id="address" placeholder="Full Name" required><!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><p class="et_pb_contact_field et_pb_contact_field_4 et_pb_contact_field_last"><!-- [et_pb_line_break_holder] --><label for="billing_address" class="et_pb_contact_form_label">Address</label><!-- [et_pb_line_break_holder] --><input type="text" class="input" id="billing_address" name="billing_address" title="Enter Valid Address" data-field_type="input" data-original_id="address" placeholder="Address" required><!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --><p class="et_pb_contact_field et_pb_contact_field_0 et_pb_contact_field_half"><!-- [et_pb_line_break_holder] --><label for="billing_city" class="et_pb_contact_form_label">City</label><!-- [et_pb_line_break_holder] --><input type="text" id="billing_city" class="input" name="billing_city" title="Enter Valid City" data-field_type="input" pattern="[a-zA-Z ]{3,}" data-original_id="name" placeholder="City" required><!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><p class="et_pb_contact_field et_pb_contact_field_1 et_pb_contact_field_half et_pb_contact_field_last"><!-- [et_pb_line_break_holder] --><label for="billing_state" class="et_pb_contact_form_label">State</label><!-- [et_pb_line_break_holder] --><input type="text" id="billing_state" class="input" name="billing_state" title="Enter Valid State" data-field_type="input" pattern="[a-zA-Z ]{3,}" data-original_id="subject" placeholder="State" required><!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><p class="et_pb_contact_field et_pb_contact_field_2 et_pb_contact_field_half"><!-- [et_pb_line_break_holder] --><label for="billing_zip" class="et_pb_contact_form_label">Zip</label><!-- [et_pb_line_break_holder] --><input type="text" id="billing_zip" class="input" name="billing_zip" title="Enter Valid Zip" data-field_type="email" pattern="[0-9]{6}" data-original_id="email" placeholder="Zip" required><!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><p class="et_pb_contact_field et_pb_contact_field_3 et_pb_contact_field_half et_pb_contact_field_last"><!-- [et_pb_line_break_holder] --><label for="billing_country" class="et_pb_contact_form_label">Country</label><!-- [et_pb_line_break_holder] --><input type="text" class="input" id="billing_country" name="billing_country" title="Enter Valid Country" data-field_type="input" pattern="[a-zA-Z ]{3,}" data-original_id="phone" placeholder="Country" required><!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><p class="et_pb_contact_field et_pb_contact_field_3 et_pb_contact_field_half et_pb_contact_field_last"><!-- [et_pb_line_break_holder] --><label for="billing_tel" class="et_pb_contact_form_label">Phone</label><!-- [et_pb_line_break_holder] --><input type="text" class="input" id="billing_tel" name="billing_tel" title="Enter Valid Mobile No" data-field_type="input" pattern="[0-9]{10}" data-original_id="phone" placeholder="Phone" required><!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><p class="et_pb_contact_field et_pb_contact_field_2 et_pb_contact_field_half"><!-- [et_pb_line_break_holder] --><label for="billing_email" class="et_pb_contact_form_label">Email Address</label><!-- [et_pb_line_break_holder] --><input type="text" id="billing_email" class="input" name="billing_email" pattern="[A-Za-z0-9._%+-]+@[A-Za-z0-9.-]+\.[A-Za-z]{1,63}$" title="Enter Valid Email Address" data-field_type="email" data-original_id="email" placeholder="Email Address" required><!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><input type="hidden" name="delivery_name" value=""/><!-- [et_pb_line_break_holder] --><input type="hidden" name="delivery_address" value=""/><!-- [et_pb_line_break_holder] --><input type="hidden" name="delivery_city" value=""/><!-- [et_pb_line_break_holder] --><input type="hidden" name="delivery_state" value=""/><!-- [et_pb_line_break_holder] --><input type="hidden" name="delivery_zip" value=""/><!-- [et_pb_line_break_holder] --><input type="hidden" name="delivery_country" value=""/><!-- [et_pb_line_break_holder] --><input type="hidden" name="delivery_tel" value=""/><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><p class="et_pb_contact_field et_pb_contact_field_4 et_pb_contact_field_last"><!-- [et_pb_line_break_holder] --><label for="merchant_param1" class="et_pb_contact_form_label">PAN No</label><!-- [et_pb_line_break_holder] --><input type="text" class="input" id="merchant_param1" name="merchant_param1" title="Enter Valid PAN No" data-field_type="input" pattern="[a-zA-Z0-9 ]{10}" data-original_id="address" placeholder="PAN No" required><!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><input type="submit" class="btn btn-2 btn-2b" value="Donate Now"><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --></form><!-- [et_pb_line_break_holder] --></div>