<h1>Payment Method Details:</h1>
<hr />
<br />
{MESSAGE}
<form method="post" action="{SELF}">
<table class="pmDetails">
<tr>
  <th>Payment Method Nickname:</th>
  <td><input type="text" name="data[nickname]" value="{NICKNAME}" style="width:200px;"></td>
</tr>
<tr>
  <th>Card Number:</th>
  <td><input type="text" name="data[card_number]" value="{CARD_NUMBER}" style="width:200px;"></td>
</tr>
<tr>
  <th>Method Type:</th>
  <td><select name="data[method_type]">{METHOD_TYPE}</select></td>
</tr>
<tr>
  <th>Card Type:</th>
  <td><select name="data[card_type]">{CARD_TYPE}</select></td>
</tr>
<tr>
  <th>Expiration Date:</th>
  <td><select name="data[exp_month]">{EXP_MONTH}</select>/<select name="data[exp_year]">{EXP_YEAR}</select></td>
</tr>
<tr>
  <th>CVV:</th>
  <td><input type="text" name="data[cvv]" value="{CVV}" style="width:50px;"></td>
<tr>
  <th>Type:</th>
  <td><select name="data[type]">{TYPE}</select></td>
</tr>
<tr>
  <th>Cardholder's Name:</th>
  <td><input type="text" name="data[cardholder_name]" value="{CARDHOLDER_NAME}" style="width:200px;"></td>
</tr>
<tr>
  <th>Address Line 1:</th>
  <td><input type="text" name="data[address1]" value="{ADDRESS1}" style="width:200px;"></td>
</tr>
<tr>
  <th>Address Line 2:</th>
  <td><input type="text" name="data[address2]" value="{ADDRESS2}" style="width:200px;"></td>
</tr>
<tr>
  <th>City:</th>
  <td><input type="text" name="data[city]" value="{CITY}" style="width:200px;"></td>
</tr>
<tr>
  <th>State:</th>
  <td><select name="data[state]">{STATE}</select></td>
</tr>
<tr>
  <th>Zip:</th>
  <td><input type="text" name="data[zip]" value="{ZIP}" style="width:60px;"></td>
</tr>
<tr>
  <td>&nbsp;</td>
  <td><input type="submit" name="data[add_card]" value="Review"></td>
</table>
</form>