1 <HTML><HEAD><TITLE>MyAccount</TITLE></HEAD>
2 <BODY BGCOLOR="#eeeeee"><FONT SIZE=5>MyAccount</FONT><BR><BR>
3 <%= $url = "$selfurl?session=$session_id;action="; ''; %>
4 <TABLE BORDER=0 CELLPADDING=4><TR>
5 <%= include('myaccount_menu') %>
7 <FONT SIZE=4>Make a payment</FONT><BR><BR>
8 <FORM NAME="OneTrueForm" METHOD="POST" ACTION="<%=$selfurl%>" onSubmit="document.OneTrueForm.process.disabled=true">
9 <INPUT TYPE="hidden" NAME="session" VALUE="<%=$session_id%>">
10 <INPUT TYPE="hidden" NAME="action" VALUE="payment_results">
11 <TABLE BGCOLOR="#cccccc">
13 <TD ALIGN="right">Amount Due</TD>
15 <TABLE><TR><TD BGCOLOR="#ffffff">
16 $<%=sprintf("%.2f",$balance)%>
21 <TD ALIGN="right">Payment amount</TD>
23 <TABLE><TR><TD BGCOLOR="#ffffff">
24 $<INPUT TYPE="text" NAME="amount" SIZE=8 VALUE="<%=sprintf("%.2f",$balance)%>">
28 <TD ALIGN="right">Card type</TD>
30 <SELECT NAME="card_type"><OPTION></OPTION>
31 <%= foreach ( keys %card_types ) {
32 $selected = $card_type eq $card_types{$_} ? ' SELECTED' : '';
33 $OUT .= qq(<OPTION$selected VALUE="). $card_types{$_}. qq(">$_\n);
38 <TD ALIGN="right">Card number</TD>
43 <INPUT TYPE="text" NAME="payinfo" SIZE=20 MAXLENGTH=19 VALUE="<%=$payinfo%>"> </TD>
47 <%= for ( ( map "0$_", 1 .. 9 ), 10 .. 12 ) {
48 $OUT .= '<OPTION'. ($_ == $month ? ' SELECTED' : ''). ">$_\n";
55 <%= my @a = localtime; for ( $a[5]+1900 .. $a[5]+1915 ) {
56 $OUT .= '<OPTION'. ($_ == $year ? ' SELECTED' : ''). ">$_\n";
64 <TD ALIGN="right">Exact name on card</TD>
65 <TD><INPUT TYPE="text" SIZE=32 MAXLENGTH=80 NAME="payname" VALUE="<%=$payname%>"></TD>
67 <TD ALIGN="right">Card billing address</TD>
69 <INPUT TYPE="text" SIZE=40 MAXLENGTH=80 NAME="address1" VALUE="<%=$address1%>">
72 <TD ALIGN="right">Address line 2</TD>
74 <INPUT TYPE="text" SIZE=40 MAXLENGTH=80 NAME="address2" VALUE="<%=$address2%>">
77 <TD ALIGN="right">City</TD>
82 <INPUT TYPE="text" NAME="city" SIZE="12" MAXLENGTH=80 VALUE="<%=$city%>">
88 $OUT .= '<OPTION'. ($_ eq $state ? ' SELECTED' : '' ). ">$_\n";
94 <INPUT TYPE="text" NAME="zip" SIZE=11 MAXLENGTH=10 VALUE="<%=$zip%>">
101 <INPUT TYPE="checkbox" CHECKED NAME="save" VALUE="1">
102 Remember this information
106 <INPUT TYPE="checkbox"<%= $payby eq 'CARD' ? ' CHECKED' : '' %> NAME="auto" VALUE="1" onClick="if (this.checked) { document.OneTrueForm.save.checked=true; }">
107 Charge future payments to this card automatically
112 <INPUT TYPE="hidden" NAME="paybatch" VALUE="<%=$paybatch%>">
113 <INPUT TYPE="submit" NAME="process" VALUE="Process payment"> <!-- onClick="this.disabled=true"> -->
117 <FONT SIZE="-2">powered by <a href="http://www.sisd.com/freeside">freeside</a></FONT>