Open-ILS/src/templates/circ/selfcheck/payment.tt2

   1 <div id='oils-selfck-cc-payment-summary'>
   2     [% l('Total amount to pay: $[_1]', '<span></span>') %]
   3 </div>
   4 <table id='oils-selfck-cc-payment-table'>
   5     <tbody>
   6         <!-- Technically not needed since card type is derived from the CC number
   7         <tr>
   8             <td>[% l('Type of Card') %]</td>
   9             <td>
  10                 <select dojoType='dijit.form.FilteringSelect' jsId='oilsSelfckCCType' required='true'>
  11                     <option value='VISA'>[% l('VISA') %]</option>
  12                     <option value='MasterCard'>[% l('MasterCard') %]</option>
  13                     <option value='American Express'>[% l('American Express') %]</option>
  14                 </select>
  15             </td>
  16         </tr>
  17         -->
  18         <tr>
  19             <td>[% l('Credit Card #') %]</td>
  20             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCNumber' required='true'/></td>
  21         </tr>
  22         <tr>
  23             <td>[% l('CVV #') %]</td>
  24             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCCVV' required='true'/></td>
  25         </tr>
  26         <tr>
  27             <td>[% l('Expiration Month') %]</td>
  28             <td>
  29                 <select dojoType='dijit.form.FilteringSelect' jsId='oilsSelfckCCMonth' required='true'>
  30                     <option value='01' selected='selected'>[% l('Jan') %]</option>
  31                     <option value='02'>[% l('Feb') %]</option>
  32                     <option value='03'>[% l('Mar') %]</option>
  33                     <option value='04'>[% l('April') %]</option>
  34                     <option value='05'>[% l('May') %]</option>
  35                     <option value='06'>[% l('June') %]</option>
  36                     <option value='07'>[% l('July') %]</option>
  37                     <option value='08'>[% l('Aug') %]</option>
  38                     <option value='09'>[% l('Sept') %]</option>
  39                     <option value='10'>[% l('Oct') %]</option>
  40                     <option value='11'>[% l('Nov') %]</option>
  41                     <option value='12'>[% l('Dec') %]</option>
  42                 </select>
  43             </td>
  44         </tr>
  45         <tr>
  46             <td>[% l('Expiration Year') %]</td>
  47             <td><input dojoType='dijit.form.NumberSpinner' constraints='{pattern:"0000", places:0, maxlength:4}' jsId='oilsSelfckCCYear' required='true'/></td>
  48         </tr>
  49         <tr>
  50             <td>[% l('Edit Billing Details') %]</td>
  51             <td><input dojoType='dijit.form.CheckBox' jsId='oilsSelfckEditDetails'/></td>
  52         </tr>
  53         <tr>
  54             <td>[% l('First Name') %]</td>
  55             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCFName' disabled='disabled' required='true'/></td>
  56         </tr>
  57         <tr>
  58             <td>[% l('Last Name') %]</td>
  59             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCLName' disabled='disabled' required='true'/></td>
  60         </tr>
  61         <tr>
  62             <td>[% l('Street Address') %]</td>
  63             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCStreet' disabled='disabled' required='true'/></td>
  64         </tr>
  65         <tr>
  66             <td>[% l('City') %]</td>
  67             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCCity' disabled='disabled' required='true'/></td>
  68         </tr>
  69         <tr>
  70             <td>[% l('State or Province') %]</td>
  71             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCState' disabled='disabled' required='true'/></td>
  72         </tr>
  73         <tr>
  74             <td>[% l('ZIP or Postal Code') %]</td>
  75             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCZip' disabled='disabled' required='true'/></td>
  76         </tr>
  77         <tr>
  78             <td colspan='2' align='center'>
  79                 <button dojoType='dijit.form.Button' jsId='oilsSelfckCCSubmit'>[% l('Submit Payment') %]</button>
  80             </td>
  81         </tr>
  82     </tbody>
  83 </table>