Solo debe reportar el pago en caso de Deposito o Transferencia Bancaria

<h1><a>Reporte de Pago</a></h1>
		<form id="form_2" class="appnitro"  method="post" action="#main_body">
					<div class="form_description">
			<h2>Reporte de Pago</h2>
			<p>Buenas, luego de haber depositado debe reportar su pago aquí</p>
		</div>						
			<ul >
			
					<li id="li_1" >
		<label class="description" for="element_1">Número de Factura <span id="required_1" class="required">*</span></label>
		<div>
			<input id="element_1" name="element_1" class="element text medium" type="text" maxlength="255" value="" /> 
		</div><p class="guidelines" id="guide_1"><small>Colocar el no de factura generada en la orden</small></p> 
		</li>		<li id="li_2" >
		<label class="description">Nombre <span id="required_2" class="required">*</span></label>
		<span>
			<input id="element_2_1" name= "element_2_1" class="element text" maxlength="255" size="8" value="" />
			<label>First</label>
		</span>
		<span>
			<input id="element_2_2" name= "element_2_2" class="element text" maxlength="255" size="14" value="" />
			<label>Last</label>
		</span><p class="guidelines" id="guide_2"><small>Coloque su Nombre y Apellido</small></p> 
		</li>		<li id="li_7" >
		<label class="description" for="element_7">Email <span id="required_7" class="required">*</span></label>
		<div>
			<input id="element_7" name="element_7" class="element text medium" type="text" maxlength="255" value="" /> 
		</div><p class="guidelines" id="guide_7"><small>Coloque su email</small></p> 
		</li>		<li id="li_10" >
		<label class="description" for="element_10">Dominio o website a contratar <span id="required_10" class="required">*</span></label>
		<div>
			<input id="element_10" name="element_10" class="element text medium" type="text" value="" /> 
		</div><p class="guidelines" id="guide_10"><small>Coloque su nombre de dominio a contratar sin http://</small></p> 
		</li>		<li id="li_4" >
		<label class="description">Fecha del Depósito <span id="required_4" class="required">*</span></label>
		<span>
			<input id="element_4_1" name="element_4_1" class="element text" size="2" maxlength="2" value="" type="text" /> /
			<label for="element_4_1">DD</label>
		</span>
		<span>
			<input id="element_4_2" name="element_4_2" class="element text" size="2" maxlength="2" value="" type="text" /> /
			<label for="element_4_2">MM</label>
		</span>
		<span>
	 		<input id="element_4_3" name="element_4_3" class="element text" size="4" maxlength="4" value="" type="text" />
			<label for="element_4_3">YYYY</label>
		</span>
	
		<span id="calendar_4">
			<img id="cal_img_4" class="datepicker" src="images/calendar.gif" alt="Pick a date." />	
		</span>
		<script type="text/javascript">
			Calendar.setup({
			inputField	 : "element_4_3",
			baseField    : "element_4",
			displayArea  : "calendar_4",
			button		 : "cal_img_4",
			ifFormat	 : "%B %e, %Y",
			onSelect	 : selectEuropeDate
			});
		</script>
		 
		</li>		<li id="li_9" >
		<label class="description">Forma de Pago <span id="required_9" class="required">*</span></label>
		<span>
			<input id="element_9_1" name="element_9_1" class="element checkbox" type="checkbox" value="1"  />
<label class="choice" for="element_9_1">Deposito Bancario</label>
<input id="element_9_2" name="element_9_2" class="element checkbox" type="checkbox" value="1"  />
<label class="choice" for="element_9_2">Transferencia Terceros</label>
<input id="element_9_3" name="element_9_3" class="element checkbox" type="checkbox" value="1"  />
<label class="choice" for="element_9_3">Transferencia Otros Bancos</label>

		</span> 
		</li>		<li id="li_5" >
		<label class="description">Banco donde depósito <span id="required_5" class="required">*</span></label>
		<span>
			<input id="element_5_1" name="element_5" class="element radio" type="radio" value="1"  />
<label class="choice" for="element_5_1">Banco Nacional de Crédito</label>
<input id="element_5_2" name="element_5" class="element radio" type="radio" value="2"  />
<label class="choice" for="element_5_2">Banco Banesco</label>
<input id="element_5_3" name="element_5" class="element radio" type="radio" value="3"  />
<label class="choice" for="element_5_3">Banco Mercantil</label>

		</span> 
		</li>		<li id="li_6" >
		<label class="description" for="element_6">Número de deposito <span id="required_6" class="required">*</span></label>
		<div>
			<input id="element_6" name="element_6" class="element text medium" type="text" maxlength="255" value="" /> 
		</div><p class="guidelines" id="guide_6"><small>Colocar ultimos nueve digitos</small></p> 
		</li>		<li id="li_8" >
		<label class="description" for="element_8">Monto del depósito <span id="required_8" class="required">*</span></label>
		<div>
			<input id="element_8" name="element_8" class="element text medium" type="text" maxlength="255" value="" /> 
		</div><p class="guidelines" id="guide_8"><small>Coloque su Monto del depósito</small></p> 
		</li>		<li id="li_captcha" > 
		<label class="description" for="element_captcha">Type the letters you see in the image below. </label>
		<div>
			<img id="captcha_image" src="captcha.php?t=1356938432" width="200" height="60" alt="Please refresh your browser to see this image." /><br />
<input id="captcha_response_field" name="captcha_response_field" class="element text small" type="text" /><div id="dummy_captcha_internal"></div>	
		</div>	 
		 
		</li>
			
					<li id="li_buttons" class="buttons">
			    <input type="hidden" name="form_id" value="2" />
			    
			    <input type="hidden" name="submit" value="1" />
				<input id="saveForm" class="button_text" type="submit" name="submit" value="Submit" />
		</li>
			</ul>
		</form>	