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<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>
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