Open-ILS/web/templates/default/circ/selfcheck/payment.tt2

   1 <div id='oils-selfck-cc-payment-summary'> </div>
   2 <table id='oils-selfck-cc-payment-table'>
   3     <tbody>
   4         <tr>
   5             <td>Amount</td>
   6             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCAmount' required='true'/></td>
   7         </tr>
   8         <tr>
   9             <td>Credit Card #</td>
  10             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCNumber' required='true'/></td>
  11         </tr>
  12         <tr>
  13             <td>Exipration Month</td>
  14             <td>
  15                 <select dojoType='dijit.form.FilteringSelect' jsId='oilsSelfckCCMonth' required='true'>
  16                     <option value='01' selected='selected'>Jan</option>
  17                     <option value='02'>Feb</option>
  18                     <option value='03'>Mar</option>
  19                     <option value='04'>April</option>
  20                     <option value='05'>May</option>
  21                     <option value='06'>June</option>
  22                     <option value='07'>July</option>
  23                     <option value='08'>Aug</option>
  24                     <option value='09'>Sept</option>
  25                     <option value='10'>Oct</option>
  26                     <option value='11'>Nov</option>
  27                     <option value='12'>Dec</option>
  28                 </select>
  29             </td>
  30         </tr>
  31         <tr>
  32             <td>Expiration Year</td>
  33             <td><input dojoType='dijit.form.NumberSpinner' constraints='{pattern:"0000", places:0, maxlength:4}' jsId='oilsSelfckCCYear' required='true'/></td>
  34         </tr>
  35         <tr>
  36             <td>Edit Billing Details</td>
  37             <td><input dojoType='dijit.form.CheckBox' jsId='oilsSelfckEditDetails'/></td>
  38         </tr>
  39         <tr>
  40             <td>First Name</td>
  41             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCFName' disabled='disabled' required='true'/></td>
  42         </tr>
  43         <tr>
  44             <td>Last Name</td>
  45             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCLName' disabled='disabled' required='true'/></td>
  46         </tr>
  47         <tr>
  48             <td>Street Address</td>
  49             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCStreet' disabled='disabled' required='true'/></td>
  50         </tr>
  51         <tr>
  52             <td>City</td>
  53             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCCity' disabled='disabled' required='true'/></td>
  54         </tr>
  55         <tr>
  56             <td>State or Province</td>
  57             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCState' disabled='disabled' required='true'/></td>
  58         </tr>
  59         <tr>
  60             <td>ZIP or Postal Code</td>
  61             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCZip' disabled='disabled' required='true'/></td>
  62         </tr>
  63         <tr>
  64             <td colspan='2' align='center'>
  65                 <button dojoType='dijit.form.Button' jsId='oilsSelfckCCSubmit'>Submit Payment</button>
  66             </td>
  67         </tr>
  68     </tbody>
  69 </table>