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<%= include('header', 'Recharge with prepaid card') %>
<FORM NAME="OneTrueForm" METHOD="POST" ACTION="<%=$selfurl%>" onSubmit="document.OneTrueForm.process.disabled=true">
<INPUT TYPE="hidden" NAME="action" VALUE="recharge_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">Prepaid card number</TD>
<TD>
<INPUT TYPE="text" NAME="prepaid_cardnum" SIZE=20 MAXLENGTH=19 VALUE="<%=$prepaid_cardnum%>">
</TD>
</TR>
</TABLE>
<BR>
<INPUT TYPE="hidden" NAME="paybatch" VALUE="<%=$paybatch%>">
<INPUT TYPE="submit" NAME="process" VALUE="Recharge"> <!-- onClick="this.disabled=true"> -->
</FORM>
<%= include('footer') %>
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