diff options
Diffstat (limited to 'ng_selfservice/elements/check.php')
| -rw-r--r-- | ng_selfservice/elements/check.php | 50 |
1 files changed, 50 insertions, 0 deletions
diff --git a/ng_selfservice/elements/check.php b/ng_selfservice/elements/check.php new file mode 100644 index 000000000..b026c92e4 --- /dev/null +++ b/ng_selfservice/elements/check.php @@ -0,0 +1,50 @@ +<TR> + <TD ALIGN="right">Account type</TD> + <TD> + <SELECT NAME="paytype"> + <? foreach ( $paytypes AS $pt ) { ?> + <OPTION <? if ($pt == $paytype ) { echo 'SELECTED'; } ?> VALUE="<? echo $pt; ?>"><? echo $pt; ?> + <? } ?> + </SELECT> + </TD> +</TR><TR> + <TD ALIGN="right">Account number</TD> + <TD><INPUT TYPE="text" NAME="payinfo1" SIZE=10 MAXLENGTH=20 VALUE="<? echo $payinfo1; ?>"></TD> +</TD><TR> + <TD ALIGN="right">ABA/Routing number</TD> + <TD><INPUT TYPE="text" NAME="payinfo2" SIZE=10 MAXLENGTH=9 VALUE="<? echo $payinfo2; ?>"></TD> +</TR><TR> + <TD ALIGN="right">Bank name</TD> + <TD><INPUT TYPE="text" SIZE=32 MAXLENGTH=80 NAME="payname" VALUE="<? echo $payname; ?>"></TD> +</TR><TR> + + <? if ($show_paystate) { ?> + <TD ALIGN="right">Bank state</TD> + <TD> + <SELECT NAME="paystate"> + <? foreach ( $states AS $s ) { ?> + <OPTION <? if ($s == $paystate ) { echo 'SELECTED'; } ?>><? echo $s; ?> + <? } ?> + </SELECT> + </TD> + </TR><TR> + <? } ?> + + <? if ($show_ss) { ?> + <TD ALIGN="right">Account holder<BR>Social security or tax ID #</TD><TD> + <INPUT TYPE="text" SIZE=32 MAXLENGTH=80 NAME="ss" VALUE="<? echo $ss; ?>"> + </TD></TR><TR> + <? } ?> + + <? if ($show_stateid) { ?> + <TD ALIGN="right"> + Account holder<BR><? echo $stateid_label; ?></TD><TD> + <INPUT TYPE="text" SIZE=32 MAXLENGTH=80 NAME="stateid" VALUE="<? echo $stateid; ?>"></TD> + <TD ALIGN="right"><? echo $stateid_state_label; ?></TD> + <TD><SELECT NAME="stateid_state"> + <? foreach ( $states AS $s ) { ?> + <OPTION <? if ($s == $stateid_state ) { echo 'SELECTED'; } ?>><? echo $s; ?> + <? } ?> + </SELECT></TD></TR><TR> + <? } ?> +</TR> |