{assign var=title value=$smarty.const._PLUG_PAY_BEANSTREAM_REM_HTML_TITLE}
{include file=$header}
<center>
<br />
<div class=hdr>{$title}</div>
<hr>

{if $error}
<table><tr><td>
{foreach from=$error item=e}
<li><font color=red><b>{$e}</b></font>
{/foreach}
</td></tr></table>
{/if}

<form name=signup method=post action="https://www.beanstream.com/scripts/process_transaction.asp">
{foreach from=$vars item=v key=k}
<input type=hidden name="{$k|escape}" value="{$v|escape}">
{/foreach} 

<table align=center class=vedit>
<tr>
    <th width=40%><b>#_PLUG_PAY_BEANSTREAM_REM_HTML_CNAME#</b><br />
    <small>#_PLUG_PAY_BEANSTREAM_REM_HTML_CNAME2|<b>|</b>#</small></th>
    <td nowrap><input type=text name=trnCardOwner value="{$smarty.request.trnCardOwner|default:$member.name}" size=30>
    </td>
</tr>
<!-- CREDIT CARD INFO -->
<tr>
    <th width=40%><b>#_PLUG_PAY_BEANSTREAM_REM_HTML_CCNUM#</b><br />
    </small></th>
    <td nowrap><input type=text name=trnCardNumber value="{$smarty.request.trnCardNumber|escape}" size=21>
    </td>
</tr>
<tr>
    <th width=40%><b>#_PLUG_PAY_BEANSTREAM_REM_HTML_CCEXP#</b><br />
    </small></th>
    <td nowrap>
      <select name="trnExpMonth">
<option value="01">#_PLUG_PAY_BEANSTREAM_REM_HTML_JAN#</option>
<option value="02">#_PLUG_PAY_BEANSTREAM_REM_HTML_FEB#</option>
<option value="03">#_PLUG_PAY_BEANSTREAM_REM_HTML_MAR#</option>
<option value="04">#_PLUG_PAY_BEANSTREAM_REM_HTML_APR#</option>

<option value="05">#_PLUG_PAY_BEANSTREAM_REM_HTML_MAY#</option>
<option value="06">#_PLUG_PAY_BEANSTREAM_REM_HTML_JUN#</option>
<option value="07">#_PLUG_PAY_BEANSTREAM_REM_HTML_JUL#</option>
<option value="08">#_PLUG_PAY_BEANSTREAM_REM_HTML_AUG#</option>
<option value="09">#_PLUG_PAY_BEANSTREAM_REM_HTML_SEP#</option>
<option value="10">#_PLUG_PAY_BEANSTREAM_REM_HTML_OCT#</option>
<option value="11">#_PLUG_PAY_BEANSTREAM_REM_HTML_NOV#</option>
<option value="12">#_PLUG_PAY_BEANSTREAM_REM_HTML_DEC#</option>
</select>

<select name=trnExpYear size=1>
{php}
for ($y=substr(date('Y'), 2, 2);$y<substr(date('Y'), 2, 2)+10;$y++,$y=sprintf('%02d', $y))
    print "<option value=$y>20$y</option>\n";
{/php}
</select>

    </td>
</tr>
<tr>
</tr>
<tr>
    <th width=40%><b>#_PLUG_PAY_BEANSTREAM_REM_HTML_ADDR#</b><br />
    <small>#_PLUG_PAY_BEANSTREAM_REM_HTML_ADDR2|<b>|</b>#</small></th>
    <td nowrap><input type=text name=ordAddress1 value="{$smarty.request.ordAddress1|default:$member.street}" size=30>
    </td>
</tr>
<tr>
    <th width=40%><b>#_PLUG_PAY_BEANSTREAM_REM_HTML_CITY#</b><br />
    <small>#_PLUG_PAY_BEANSTREAM_REM_HTML_CITY2|<b>|</b>#
    </small></th>
    <td nowrap><input type=text name=ordCity value="{$smarty.request.ordCity|default:$member.city}" size=30>
    </td>
</tr>
<tr>
    <th width=40%><b>#_PLUG_PAY_BEANSTREAM_REM_HTML_COUNTRY#</b><br />
    <small>#_PLUG_PAY_BEANSTREAM_REM_HTML_COUNTRY2|<b>|</b>#
    </small></th>
    <td nowrap><select name=ordCountry size=1>
    {html_options selected=$member.country options=$config.country_options}
    </select>
    </td>
</tr>
<tr>
    <th width=40%><b>#_PLUG_PAY_BEANSTREAM_REM_HTML_STATE#</b><br />
    <small>#_PLUG_PAY_BEANSTREAM_REM_HTML_STATE2|<b>|</b>#
    </small></th>
    <td nowrap>
    <select name=ordProvince size=1>
    {html_options selected=$member.state options=$config.state_options}
    </select>

    </td>
</tr>
<tr>
    <th width=40%><b>#_PLUG_PAY_BEANSTREAM_REM_HTML_ZIP#</b><br />
    </small></th>
    <td nowrap><input type=text name=ordPostalCode value="{$smarty.request.ordPostalCode|default:$member.zip}" size=30>
    </td>
</tr>
<tr>
    <th width=40%><b>#_PLUG_PAY_BEANSTREAM_REM_HTML_PHONE#</b><br />
    </small></th>
    <td nowrap><input type=text name=ordPhoneNumber value="{$smarty.request.ordPhoneNumber|default:$member.data.phone}" size=30>
    </td>
</tr>
</table>
<input type=submit value=#_PLUG_PAY_BEANSTREAM_REM_HTML_PROCEED#>

<i>#_PLUG_PAY_BEANSTREAM_REM_HTML_FSUMB#</i>
</form>
</center>
{include file=$footer}