Open-ILS/src/templates/opac/myopac/generic_payment_form.tt2

   1 <form method="post" id="payment_form" action='#payment'>
   2     <input type="hidden" name="last_chance" value="1" />
   3     [% FOR xact IN CGI.param('xact') %]
   4     <input type="hidden" name="xact" value="[% xact | html %]" />
   5     [% END %]
   6     [% FOR xact IN CGI.param('xact_misc') %]
   7     <input type="hidden" name="xact_misc" value="[% xact | html %]" />
   8     [% END %]
   9
  10      <table id="billing_info_table">
  11       <tbody>
  12           <tr>
  13               <td colspan='2' class="cc_header"><strong>[% l('Billing Information') %]</strong></td>
  14            </tr>
  15            <tr>
  16             <td><label for="payment-first-name">[% l('First Name') %]</label></td>
  17                 <td><input type="text"  name="billing_first" id="payment-first-name"
  18                     value="[% ctx.user.first_given_name | html %]" /></td>
  19             </tr>
  20             <tr>
  21                 <td><label for="payment-last-name">[% l('Last Name') %]</label></td>
  22                 <td><input type="text" name="billing_last" id="payment-last-name"
  23                     value="[% ctx.user.family_name | html %]" /></td>
  24             </tr>
  25
  26             <tr>
  27                 <td><label for="payment-email-addr">[% l('Email Address') %]</label></td>
  28                 <td>
  29
  30                     <input id="payment-email-addr" type="text"
  31                          value="[% ctx.user.email | html %]" disabled="disabled"
  32                         readonly="readonly" />
  33                     <a title="[% l('Update Email Address') %]"
  34                         href="[% ctx.opac_root %]/myopac/update_email?return_to_referer=1">[% l("Update") %]</a>
  35                 </td>
  36             </tr>
  37             <tr>
  38                 <td><label for="payment-billing-address">[% l('Street Address') %]</label></td>
  39                 <td><input type="text" name="billing_address" id="payment-billing-address"
  40                     value="[% ctx.user.billing_address.street1 _ ctx.user.billing_address.street2 | html %]" /></td>
  41             </tr>
  42             <tr>
  43                 <td><label for="payment-billing-city">[% l('City' )%]</label></td>
  44                 <td><input type="text" name="billing_city" id="payment-billing-city"
  45                     value="[% ctx.user.billing_address.city | html %]" /></td>
  46             </tr>
  47             <tr>
  48                 <td><label for="payment-billing-state">[% l('State or Province') %]</label></td>
  49                 <td><input type="text" name="billing_state" id="payment-billing-state"
  50                     value="[% ctx.user.billing_address.state | html %]" /></td>
  51             </tr>
  52             <tr>
  53                 <td><label for="paymenet-billing-zip">[% l('ZIP or Postal Code') %]</label></td>
  54                 [% USE zip=String(ctx.user.billing_address.post_code) %]
  55                 <td><input type="tel" pattern="[0-9]*" maxlength="5" size="5" name="billing_zip" id="paymenet-billing-zip"
  56                     value="[% zip.truncate(5)  %]" /></td>
  57             </tr>
  58            </tbody>
  59            </table>
  60
  61            <table id="credit_card_info_table">
  62            <tbody>
  63             <tr>
  64               <td colspan='2' class="cc_header"><strong>[% l('Credit Card Information') %]</strong></td>
  65             </tr>
  66             <tr>
  67                 <td><label for="payment-credit-card">[% l('Credit Card #') %]</label></td>
  68
  69                  <!-- Make type tel, which prompts for numbers in mobile -->
  70                 <td><input type="tel" pattern="[0-9]*" maxlength="16" id="payment-credit-card" required name="number"/></td>
  71             </tr>
  72             <tr>
  73                 <td><label for="payment-security-code">[% l('Security Code') %]</label></td>
  74                 <td>
  75                      <!-- Make type tel, which prompts for numbers in mobile -->
  76                     <input type="tel" pattern="[0-9]*" size="4" maxlength="5" id="payment-security-code" name="cvv2"/></td>
  77             </tr>
  78             <tr>
  79                 <td><label for="payment-expire-month">[% l('Expiration Month') %]</label></td>
  80                 <td>
  81                     <select id="payment-expire-month" required name="expire_month">
  82                         <option value="-1"></option>
  83                         <option value="01">[% l("January (1)") %]</option>
  84                         <option value="02">[% l("February (2)") %]</option>
  85                         <option value="03">[% l("March (3)") %]</option>
  86                         <option value="04">[% l("April (4)") %]</option>
  87                         <option value="05">[% l("May (5)") %]</option>
  88                         <option value="06">[% l("June (6)") %]</option>
  89                         <option value="07">[% l("July (7)") %]</option>
  90                         <option value="08">[% l("August (8)") %]</option>
  91                         <option value="09">[% l("September (9)") %]</option>
  92                         <option value="10">[% l("October (10)") %]</option>
  93                         <option value="11">[% l("November (11)") %]</option>
  94                         <option value="12">[% l("December (12)") %]</option>
  95                     </select>
  96                 </td>
  97             </tr>
  98             <tr>
  99                 <td><label for="payment-expire-year">[% l('Expiration Year') %]</label></td>
 100                 <td>
 101                     <select id="payment-expire-year" name="expire_year">
 102                     [% year = date.format(date.now, '%Y');
 103                     y = year;
 104                     WHILE y < year + 10; # show ten years starting now %]
 105                         <option value="[% y %]">[% y %]</option>
 106                     [% y = y + 1; END %]
 107                     </select>
 108                 </td>
 109             </tr>
 110             <tr>
 111                <td colspan='2'>
 112                    <div id="payment_actions">
 113                       [% l('Total amount:') %]
 114                        <strong>[% money(ctx.fines.balance_owed) %]</strong><br />
 115
 116                      <input type="submit" id="payment_submit" value="[% l('Next') %]" class="opac-button" />
 117                      <a href="[% mkurl(ctx.opac_root _ '/myopac/main', {}, 1) %]" class="opac-button">[% l('Cancel') %]</a>
 118                      <br/>
 119
 120
 121                    </div>
 122                </td>
 123             </tr>
 124
 125       </tbody>
 126     </table>
 127 </form>
 128 <table width="100%">[% INCLUDE "opac/parts/myopac/main_refund_policy.tt2" %]</table>