<form class="bitpay-donate form-horizontal" action="https://bitpay.com/checkout" method="POST" onsubmit="return checkRequiredFields(this);">

            <input name="action" type="hidden" value="checkout">

            <div class="form-group">

              <label class="col-sm-2 control-label">Email:</label>

              <div class="col-sm-10">

                <input class="bitpay-donate-field-email form-control" name="orderID" type="email" placeholder="Email address (optional)" maxlenght=50 autocapitalize=off autocorrect=off />

              </div>

            <div class="form-group">

              <label class="col-sm-2 control-label">Amount:</label>

              <div class="col-sm-10">

                <input class="bitpay-donate-field-price form-control" style="display: inline;" name="price" type="number" value="0.1" placeholder="Amount" maxlenght="10" min="0.000006" step="0.000001" />

                <select class="bitpay-donate-field-currency form-control" style="display: inline;" value="" name="currency">

                  <option selected="selected" value="BTC">BTC</option>

                  <option value="USD">USD</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>

            <input type="hidden" name="data" value="k3TZs7wPLcCaurVVZ8iW/MCwDwe94LwJrA22SKBNMwOmVLQ3AAW4TncxqpNFPVNScSCIqoQR+zwgYJSRtFBFciNwQ7Ezcnqb3JptfVNnDubnNy1KVTFCYXZ8m/83aFxFC0p6Lyf07a0HCEWTBMQhmVjFLuQYSa57kYQd+fzlL+lbi5pkBW8ok884l1ELYq6W">

            <div class="bitpay-donate-button-wrapper form-group">

              <input class="bitpay-donate-button" name="submit" src="https://bitpay.com/img/donate-button.svg" onerror="this.onerror=null; this.src='https://bitpay.com/img/donate-button-md.png'" width="126" height="48" type="image" alt="BitPay, the easy way the easy way to pay with bitcoins." border="0">

            </div>

          </form>

        </div>