diff options
Diffstat (limited to 'fs_selfservice/FS-SelfService/cgi/make_payment.html')
| -rw-r--r-- | fs_selfservice/FS-SelfService/cgi/make_payment.html | 119 |
1 files changed, 119 insertions, 0 deletions
diff --git a/fs_selfservice/FS-SelfService/cgi/make_payment.html b/fs_selfservice/FS-SelfService/cgi/make_payment.html new file mode 100644 index 0000000..3522c08 --- /dev/null +++ b/fs_selfservice/FS-SelfService/cgi/make_payment.html @@ -0,0 +1,119 @@ +<HTML><HEAD><TITLE>MyAccount</TITLE></HEAD> +<BODY BGCOLOR="#eeeeee"><FONT SIZE=5>MyAccount</FONT><BR><BR> +<%= $url = "$selfurl?session=$session_id;action="; ''; %> +<TABLE BORDER=0 CELLPADDING=4><TR> +<%= include('myaccount_menu') %> +<TD VALIGN="top"> +<FONT SIZE=4>Make a payment</FONT><BR><BR> +<FORM NAME="OneTrueForm" METHOD="POST" ACTION="<%=$selfurl%>" onSubmit="document.OneTrueForm.process.disabled=true"> +<INPUT TYPE="hidden" NAME="session" VALUE="<%=$session_id%>"> +<INPUT TYPE="hidden" NAME="action" VALUE="payment_results"> +<TABLE BGCOLOR="#cccccc"> +<TR> + <TD ALIGN="right">Amount Due</TD> + <TD> + <TABLE><TR><TD BGCOLOR="#ffffff"> + $<%=sprintf("%.2f",$balance)%> + </TD></TR></TABLE> + </TD> +</TR> +<TR> + <TD ALIGN="right">Payment amount</TD> + <TD> + <TABLE><TR><TD BGCOLOR="#ffffff"> + $<INPUT TYPE="text" NAME="amount" SIZE=8 VALUE="<%=sprintf("%.2f",$balance)%>"> + </TD></TR></TABLE> + </TD> +</TR><TR> + <TD ALIGN="right">Card type</TD> + <TD> + <SELECT NAME="card_type"><OPTION></OPTION> + <%= foreach ( keys %card_types ) { + $selected = $card_type eq $card_types{$_} ? ' SELECTED' : ''; + $OUT .= qq(<OPTION$selected VALUE="). $card_types{$_}. qq(">$_\n); + } %> + </SELECT> + </TD> +</TD><TR> + <TD ALIGN="right">Card number</TD> + <TD> + <TABLE> + <TR> + <TD> + <INPUT TYPE="text" NAME="payinfo" SIZE=20 MAXLENGTH=19 VALUE="<%=$payinfo%>"> </TD> + <TD>Exp.</TD> + <TD> + <SELECT NAME="month"> + <%= for ( ( map "0$_", 1 .. 9 ), 10 .. 12 ) { + $OUT .= '<OPTION'. ($_ == $month ? ' SELECTED' : ''). ">$_\n"; + } %> + </SELECT> + </TD> + <TD> / </TD> + <TD> + <SELECT NAME="year"> + <%= my @a = localtime; for ( $a[5]+1900 .. $a[5]+1915 ) { + $OUT .= '<OPTION'. ($_ == $year ? ' SELECTED' : ''). ">$_\n"; + } %> + </SELECT> + </TD> + </TR> + </TABLE> + </TD> +</TR><TR> + <TD ALIGN="right">Exact name on card</TD> + <TD><INPUT TYPE="text" SIZE=32 MAXLENGTH=80 NAME="payname" VALUE="<%=$payname%>"></TD> +</TR><TR> + <TD ALIGN="right">Card billing address</TD> + <TD> + <INPUT TYPE="text" SIZE=40 MAXLENGTH=80 NAME="address1" VALUE="<%=$address1%>"> + </TD> +</TR><TR> + <TD ALIGN="right">Address line 2</TD> + <TD> + <INPUT TYPE="text" SIZE=40 MAXLENGTH=80 NAME="address2" VALUE="<%=$address2%>"> + </TD> +</TR><TR> + <TD ALIGN="right">City</TD> + <TD> + <TABLE> + <TR> + <TD> + <INPUT TYPE="text" NAME="city" SIZE="12" MAXLENGTH=80 VALUE="<%=$city%>"> + </TD> + <TD>State</TD> + <TD> + <SELECT NAME="state"> + <%= for ( @states ) { + $OUT .= '<OPTION'. ($_ eq $state ? ' SELECTED' : '' ). ">$_\n"; + } %> + </SELECT> + </TD> + <TD>Zip</TD> + <TD> + <INPUT TYPE="text" NAME="zip" SIZE=11 MAXLENGTH=10 VALUE="<%=$zip%>"> + </TD> + </TR> + </TABLE> + </TD> +</TR><TR> + <TD COLSPAN=2> + <INPUT TYPE="checkbox" CHECKED NAME="save" VALUE="1"> + Remember this information + </TD> +</TR><TR> + <TD COLSPAN=2> + <INPUT TYPE="checkbox"<%= $payby eq 'CARD' ? ' CHECKED' : '' %> NAME="auto" VALUE="1" onClick="if (this.checked) { document.OneTrueForm.save.checked=true; }"> + Charge future payments to this card automatically + </TD> +</TR> +</TABLE> +<BR> +<INPUT TYPE="hidden" NAME="paybatch" VALUE="<%=$paybatch%>"> +<INPUT TYPE="submit" NAME="process" VALUE="Process payment"> <!-- onClick="this.disabled=true"> --> +</FORM> +</TD></TR></TABLE> +<HR> +<FONT SIZE="-2">powered by <a href="http://www.sisd.com/freeside">freeside</a></FONT> +</BODY></HTML> + |