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[working/Evergreen.git] / Open-ILS / web / templates / default / circ / selfcheck / payment.tt2
1 <div id='oils-selfck-cc-payment-summary'>
2     Total amount to pay: $<span></span>
3 </div>
4 <table id='oils-selfck-cc-payment-table'>
5     <tbody>
6         <tr>
7             <td>Credit Card #</td>
8             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCNumber' required='true'/></td>
9         </tr>
10         <tr>
11             <td>CVV #</td>
12             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCCVV' required='true'/></td>
13         </tr>
14         <tr>
15             <td>Exipration Month</td>
16             <td>
17                 <select dojoType='dijit.form.FilteringSelect' jsId='oilsSelfckCCMonth' required='true'>
18                     <option value='01' selected='selected'>Jan</option>
19                     <option value='02'>Feb</option>
20                     <option value='03'>Mar</option>
21                     <option value='04'>April</option>
22                     <option value='05'>May</option>
23                     <option value='06'>June</option>
24                     <option value='07'>July</option>
25                     <option value='08'>Aug</option>
26                     <option value='09'>Sept</option>
27                     <option value='10'>Oct</option>
28                     <option value='11'>Nov</option>
29                     <option value='12'>Dec</option>
30                 </select>
31             </td>
32         </tr>
33         <tr>
34             <td>Expiration Year</td>
35             <td><input dojoType='dijit.form.NumberSpinner' constraints='{pattern:"0000", places:0, maxlength:4}' jsId='oilsSelfckCCYear' required='true'/></td>
36         </tr>
37         <tr>
38             <td>Edit Billing Details</td>
39             <td><input dojoType='dijit.form.CheckBox' jsId='oilsSelfckEditDetails'/></td>
40         </tr>
41         <tr>
42             <td>First Name</td>
43             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCFName' disabled='disabled' required='true'/></td>
44         </tr>
45         <tr>
46             <td>Last Name</td>
47             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCLName' disabled='disabled' required='true'/></td>
48         </tr>
49         <tr>
50             <td>Street Address</td>
51             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCStreet' disabled='disabled' required='true'/></td>
52         </tr>
53         <tr>
54             <td>City</td>
55             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCCity' disabled='disabled' required='true'/></td>
56         </tr>
57         <tr>
58             <td>State or Province</td>
59             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCState' disabled='disabled' required='true'/></td>
60         </tr>
61         <tr>
62             <td>ZIP or Postal Code</td>
63             <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCZip' disabled='disabled' required='true'/></td>
64         </tr>
65         <tr>
66             <td colspan='2' align='center'>
67                 <button dojoType='dijit.form.Button' jsId='oilsSelfckCCSubmit'>Submit Payment</button>
68             </td>
69         </tr>
70     </tbody>
71 </table>