gistfile1.haml

.bottom-form
					%h3 Is This For:
					%input{:name => "employeeIncentives", :type => "checkbox", :value => "employeeIncentives"}
					%label.textlabel{:for => "employeeIncentives"} Employee Incentives
					%input{:name => "corporateLoyalty", :type => "checkbox", :value => "corporateLoyalty"}
					%label.textlabel{:for => "corporateLoyalty"} Corporate Loyalty Program*
					%input{:name => "nonProfit", :type => "checkbox", :value => "nonProfit"}
					%label.textlabel{:for => "nonProfit"} Non-Profit Fundraiser
					%input{:name => "corporateGifting", :type => "checkbox", :value => "corporateGifting"}
					%label.textlabel{:for => "corporateGifting"} Corporate Gifting
					%h3 Giftcard(s) - Tell us more about your bulk gift card purchase.
					%textarea.textInput.inputbox{:name => "name", :row => "2"}
					%h3 Payment Method
					.payBycheck
						%input{:name => "employeeIncentives", :type => "checkbox", :value => "employeeIncentives"}
						%label.textlabel{:for => "employeeIncentives"} Check
					.payableTo
						%p 
							%strong Payable to:
						%p CouponTrade, Inc.
						%p 214 West Ohio Street, Suite 4
						%p Chicago, IL 60654
					.payment-side
						%input{:name => "corporateLoyalty", :type => "checkbox", :value => "corporateLoyalty"}
						%label.textlabel{:for => "corporateLoyalty"} **Credit Card
						%br
							%input{:name => "nonProfit", :type => "checkbox", :value => "nonProfit"}
							%label.textlabel{:for => "nonProfit"} Visa
							%input{:name => "corporateGifting", :type => "checkbox", :value => "corporateGifting"}
							%label.textlabel{:for => "corporateGifting"} MC
							%input{:name => "corporateGifting", :type => "checkbox", :value => "corporateGifting"}
							%label.textlabel{:for => "corporateGifting"} AMEX
							%input{:name => "corporateGifting", :type => "checkbox", :value => "corporateGifting"}
							%label.textlabel{:for => "corporateGifting"} DISCOVER
							%p Last Four Digits of Credit Card #:
					.clear