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<input type="hidden" name="on1" value="Level">Level<br />

<select name="os1">

<option value="Bronze">Bronze 15.00</option>
<option value="Silver">Silver 25.00</option>
<option value="Gold">Gold 45.00</option>

</select>

<input type="hidden" name="option_index" value="1">

<input type="hidden" name="option_select0" value="Bronze">
<input type="hidden" name="option_amount0" value="15.00">

<input type="hidden" name="option_select1" value="Silver">
<input type="hidden" name="option_amount1" value="25.00">

<input type="hidden" name="option_select2" value="Gold">
<input type="hidden" name="option_amount2" value="45.00">