<label for=identidad>NIF* pel qual vols pagar</label>[text* dni placeholder "12345678Z"]
<h4>[response]</h4>
<h4>Pagament amb targeta de crèdit</h4>
<table width="100%">
<tbody>
<tr>
<td width="66%"><span style="color: #008080;"><strong>Data de pagament</strong></span></td>
<td width="16%"><span style="color: #008080;"><strong>Associats*</strong></span></td>
<td width="16%"><span style="color: #008080;"><strong>No associats</strong></span></td>
</tr>
<tr>
<td>De l'1 al 15 de juny de 2016</td>
<td> [radio preus   "95"]€ </td>
<td> [radio preus default:1 "120"]€</td>
</tr>
<tr>
<td>Sessions específiques 0 a 3. Matí 12 de juliol</td>
<td colspan="2">[radio preus  "30"]€</td>
</tr>
</tbody>
</table>
[c2em_num_ordre]
<h4>[response]</h4>
[submit "Fes el pagament"]
