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