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mountain bob

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My "Silver" subscription expired yesterday, so I cannot ask this question with a Support Ticket.
When I click on the button to renew my subscription, a small "form" comes up with three boxes for data entry.

The boxes are not labelled. Each box has a tiny icon in it -- I presume that the little icons are supposed to provide a clue as to what data I should input into each of the entry boxes.
BUT hovering over the little icons does not trigger any "pop-up" labels or additional identifying info.

I do not want to experiment with randomly entering credit card information (maybe card number, "name on card", expiration date, etc.) in unidentified boxes.

How might I find out what that Form wants, or discover some other way to renew my subscription?