<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 FINAL//EN">
<html>
<head>
<title></title>
<script name="javascript">
function putValue(sValue) {
sValue = sValue.split(':');
document.forms[0].dollarAmt.value = sValue[0];
document.forms[0].otherText.value = sValue[1];
}
</script>
<style type="text/css">
</style>
<meta name="author" content="?">
<meta name="keywords" content="?">
<meta name="description" content="?">
</head>
<body onload="">
<form>
<select name="mLevel" onchange="putValue(this.options[this.selectedIndex].value);">
<option value="">Choose:</option>
<option value="25:otherBronze">Bronze</option>
<option value="50:otherSilver">Silver</option>
<option value="100:otherGold">Gold</option>
<option value="?:type your own">Other</option>
</select>
<p />
<input type="text" name="dollarAmt" />
<input type="text" name="otherText" />
</form>
</body>
</html>