<form method="post">
<input type="hidden" name="a" value="withdraw">
<input type="hidden" name="action" value="preview">
<div class="balance">
<div class="txt_b">Your current balance:</div>
<div class="sum_b">0.00184246 <span>BTC</span></div>
</div>
<table cellspacing="0" cellpadding="2" border="0" class="tables2">
<tbody><tr>
<td>Pending Withdrawals: </td>
<td>Ƀ<b>0.00120000</b></td>
</tr>
<tr>
<td>Your Bitcoin Account:</td>
<td>1Nr7ZrVxJogvSJi1kuihvMj7wjLaEjXScK</td>
</tr>
</tbody></table>
<table cellspacing="0" cellpadding="2" border="0">
<tbody><tr>
<td colspan="2"> </td>
</tr>
<tr>
<td><div class="label">Select eCurrency:</div></td>
<td>
<div class="select blocks">
<div class="int"><input type="text" style="display: inline-block;"></div>
<select name="ec" class="inpts" style="opacity: 0;">
<option value="48">Bitcoin</option>
</select>
</div>
</td>
</tr><tr>
<td><div class="label">Withdrawal (Ƀ):</div></td>
<td><div class="int"><input type="text" name="amount" value="10.00" class="inpts" size="15"></div></td>
</tr><tr>
<td></td>
<td><div class="int"><textarea name="comment" class="inpts" cols="45" rows="4">Your comment</textarea></div>
</td></tr>
<tr>
<td> </td>
<td><button type="submit" value="Request" class="btn">Request</button></td>
</tr></tbody></table>
</form>
