first name
last name
street
city
state - AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI
zip code
email
Card Number
Expiration Date - 01 02 03 04 05 06 07 08 09 10 11 12 / - 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042
Security Code
Amount $
please rewrite the code from the picture below
