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Form Issue - TheJokerHck - 2015-12-14

Hello. I have setup a payment form on my forum with a text box and button but the data entered in the box is not being shown on the payment processor site (Coin Payments) 

If someone could take a look please. Thank you

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I would simply like it to where they can enter their username or UID and it shows up on my end so I know who purchased the membership.