<html> <body> <form method="post" name="centinel-form" action="cmpi_lookup_response.php"> <label for="first_name">First name: </label> <input type="text" name="first_name" id="first_name" value="John"><br> <label for="last_name">Last name: </label> <input type="text" name="last_name" id= "last_name" value="Doe"><br> <label for="card_number">Card number: </label> <select name="card_number" id="card_number"> <option value="4000000000000002">4000000000000002( Test case 1 )</option> <option value="4000000000000010">4000000000000010( Test case 2 )</option> <option value="4000000000000028">4000000000000028( Test case 3 )</option> <option value="4000000000000101">4000000000000101( Test case 4 )</option> <option value="4000000000000044">4000000000000044( Test case 5 )</option> <option value="4000000000000051">4000000000000051( Test case 6 )</option> <option value="4000000000000069">4000000000000069( Test case 7 )</option> <option value="4000000000000077">4000000000000077( Test case 8 )</option> <option value="4000000000000085">4000000000000085( Test case 9 )</option> <option value="4000000000000093">4000000000000093( Test case 10 )</option> <option value="4000000000000036">4000000000000036( Test case 11 )</option> </select> <br> <label for="verification_value">CVV: </label> <input type="text" name="verification_value" id= "verification_value" value="000" size="3" maxlength="3"><br> <label for="month">Month: </label> <select name="month" id="month"> <?php for ($i=1; $i<=12; $i++): ?> <option value="<?php echo $i?>"><?php echo $i?></option> <?php endfor;?> </select> <label for="year">Year: </label> <select name="year" id="year"> <?php for ($i=2011; $i<=2020; $i++): ?> <option value="<?php echo $i?>"><?php echo $i?></option> <?php endfor;?> </select> <br> <input type="submit" name="submit-cmpi-lookup" value="Submit Lookup"> </form> </body></html>