1 files changed, 54 insertions, 0 deletions
diff --git a/fs_selfservice/FS-SelfService/cgi/check.html b/fs_selfservice/FS-SelfService/cgi/check.html
new file mode 100644
index 000000000..68753fe08
--- /dev/null
+++ b/fs_selfservice/FS-SelfService/cgi/check.html
@@ -0,0 +1,54 @@
+<TR>
+  <TD ALIGN="right">Account&nbsp;type</TD>
+  <TD>
+    <SELECT NAME="paytype">
+      <%= foreach ( @paytypes ) {
+            $selected = $paytype eq $_ ? ' SELECTED' : '';
+            $OUT .= qq(<OPTION$selected VALUE="$_">$_\n);
+      } %>
+    </SELECT>
+  </TD>
+</TD><TR>
+  <TD ALIGN="right">Account&nbsp;number</TD>
+  <TD><INPUT TYPE="text" NAME="payinfo1" SIZE=10 MAXLENGTH=20 VALUE="<%=$payinfo1%>"></TD>
+</TD><TR>
+  <TD ALIGN="right">ABA/Routing&nbsp;number</TD>
+  <TD><INPUT TYPE="text" NAME="payinfo2" SIZE=10 MAXLENGTH=9 VALUE="<%=$payinfo2%>"></TD>
+</TR><TR>
+  <TD ALIGN="right">Bank&nbsp;name</TD>
+  <TD><INPUT TYPE="text" SIZE=32 MAXLENGTH=80 NAME="payname" VALUE="<%=$payname%>"></TD>
+</TR><TR>
+  <%=
+    $OUT = '';
+    if ($show_paystate) {
+      $OUT .= qq!<TD ALIGN="right">Bank state</TD><TD><SELECT NAME="paystate">!;
+      for ( @states ) {
+        $OUT .= '<OPTION'. ($_ eq $paystate ? ' SELECTED' : '' ). ">$_\n";
+      }
+      $OUT .= '</SELECT></TD></TR><TR>';
+    }
+  %>
+  <%=
+    $OUT = '';
+    if ($show_ss) {
+      $OUT .= '<TD ALIGN="right">Account&nbsp;holder<BR>Social&nbsp;';
+      $OUT .= 'security&nbsp;or&nbsp;tax&nbsp;ID&nbsp;#</TD><TD>';
+      $OUT .= qq!<INPUT TYPE="text" SIZE=32 MAXLENGTH=80 NAME="ss" VALUE="$ss">!;
+      $OUT .= '</TD></TR><TR>';
+    }
+  %>
+  <%=
+    $OUT = '';
+    if ($show_stateid) {
+      $OUT .= '<TD ALIGN="right">';
+      $OUT .= qq!Account&nbsp;holder<BR>$stateid_label</TD><TD>!;
+      $OUT .= qq!<INPUT TYPE="text" SIZE=32 MAXLENGTH=80 NAME="stateid" VALUE="$stateid"></TD>!;
+      $OUT .= qq!<TD ALIGN="right">$stateid_state_label</TD>!;
+      $OUT .= '<TD><SELECT NAME="stateid_state">';
+      for ( @states ) {
+        $OUT .= '<OPTION'. ($_ eq $stateid_state ? ' SELECTED' : '' ). ">$_\n";
+      }
+      $OUT .='</SELECT></TD></TR><TR>';
+    }
+  %>
+</TR>