<!-- start eload form -->
<link rel="stylesheet" type="text/css" href="http://www.plugntalkload.com/affiliate/css/shoreaccess.css" />
<form method="post" action="http://www.plugntalkload.com/buycredits.php" target="_blank">
<input type="hidden" name="affid" value="7" />
<input type="hidden" name="partnercode" value="shoreaccess" />
<div class="mobilenowrapper">
<label>SMART Mobile number:</label>
<input type="text" name="mobileno" value="" size="20" />
<span class="mobilenoex">
Ex. 09217741366
</span>
</div>
<span class="mobilenoex">
<label style="margin-top:5px;">Choose an amount to load:</label>
</span>
<div class="itemwrapper">
<input type="radio" name="amount" value="30" /> <strong>Php 30.00</strong>
<span class="validity">(Valid for 15 days) ($1.25)</span>
</div>
<div class="itemwrapper">
<input type="radio" name="amount" value="60" /> <strong>Php 60.00</strong>
<span class="validity">(Valid for 30 days) ($2.25)</span>
</div>
<div class="itemwrapper">
<input type="radio" checked="checked" name="amount" value="200" /> <strong>Php 200.00</strong>
<span class="validity">(Valid for 60 days) ($5.25)</span>
</div>
<div class="itemwrapper">
<input type="radio" name="amount" value="300" /> <strong>Php 300.00</strong>
<span class="validity">(Valid for 75 days) ($7.50)</span>
</div>
<div class="itemwrapper">
<input type="radio" name="amount" value="500" /> <strong>Php 500.00</strong>
<span class="validity">(Valid for 120 days) ($12.25)</span>
</div>
<div class="submitbtnwrapper">
<input type="submit" name="submitbtn" value="Send Load Now!" style="font-size:16px;font-weight:bold;color:#006699" />
</div>
</form>
<!-- end eload form -->