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