1 <div id='oils-selfck-cc-payment-summary'>
2 Total amount to pay: $<span></span>
4 <table id='oils-selfck-cc-payment-table'>
6 <!-- Technically not needed since card type is derived from the CC number
10 <select dojoType='dijit.form.FilteringSelect' jsId='oilsSelfckCCType' required='true'>
11 <option value='VISA'>VISA</option>
12 <option value='MasterCard'>MasterCard</option>
13 <option value='American Express'>American Express</option>
19 <td>Credit Card #</td>
20 <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCNumber' required='true'/></td>
24 <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCCVV' required='true'/></td>
27 <td>Exipration Month</td>
29 <select dojoType='dijit.form.FilteringSelect' jsId='oilsSelfckCCMonth' required='true'>
30 <option value='01' selected='selected'>Jan</option>
31 <option value='02'>Feb</option>
32 <option value='03'>Mar</option>
33 <option value='04'>April</option>
34 <option value='05'>May</option>
35 <option value='06'>June</option>
36 <option value='07'>July</option>
37 <option value='08'>Aug</option>
38 <option value='09'>Sept</option>
39 <option value='10'>Oct</option>
40 <option value='11'>Nov</option>
41 <option value='12'>Dec</option>
46 <td>Expiration Year</td>
47 <td><input dojoType='dijit.form.NumberSpinner' constraints='{pattern:"0000", places:0, maxlength:4}' jsId='oilsSelfckCCYear' required='true'/></td>
50 <td>Edit Billing Details</td>
51 <td><input dojoType='dijit.form.CheckBox' jsId='oilsSelfckEditDetails'/></td>
55 <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCFName' disabled='disabled' required='true'/></td>
59 <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCLName' disabled='disabled' required='true'/></td>
62 <td>Street Address</td>
63 <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCStreet' disabled='disabled' required='true'/></td>
67 <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCCity' disabled='disabled' required='true'/></td>
70 <td>State or Province</td>
71 <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCState' disabled='disabled' required='true'/></td>
74 <td>ZIP or Postal Code</td>
75 <td><input dojoType='dijit.form.TextBox' jsId='oilsSelfckCCZip' disabled='disabled' required='true'/></td>
78 <td colspan='2' align='center'>
79 <button dojoType='dijit.form.Button' jsId='oilsSelfckCCSubmit'>Submit Payment</button>