<h1>One Time Payment</h1>
<hr />
<form method="post" action="{SELF}">
<input type="hidden" name="data[payment_method]" value="{PAYMENT_METHOD}">
<input type="hidden" name="data[payment_opt]" value="{PAYMENT_OPT}">
<input type="hidden" name="data[past_due]" value="{PAST_DUE}">
<input type="hidden" name="data[current_balance]" value="{CURRENT_BALANCE}">
<input type="hidden" name="data[payment_amount]" value="{PAYMENT_AMOUNT}">
<input type="hidden" name="data[payment_date]" value="{PAYMENT_DATE}">
<input type="hidden" name="data[nickname]" value="{NICKNAME}">
{MESSAGE}
<h2>Payment Information:</h2>
Please fill the required details for the selected payment method.
<br /><br />
<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}</td>
</tr>
<tr>
  <th>Card Type:</th>
  <td>{CARD_TYPE}</th>
</tr>
<tr>
  <th>Expiration Date:</th>
  <td>{EXP_MONTH}/{EXP_YEAR}</td>
</tr>
<tr>
  <th>Security Code:</th>
  <td><input type="text" name="data[cvv]" value="{CVV}" size=4></td>
</tr>
<tr>
  <th>Type:</th>
  <td>{TYPE}</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>&nbsp;</td>
  <td align="right"><input type="submit" name="data[uap]" value="Back"> <input type="submit" name="data[uap]" value="Review"></td>
</tr>
</table>
</form>