<h1>One Time Payment: Review</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[payment_amount]" value="{PAYMENT_AMOUNT}">
<input type="hidden" name="data[payment_date]" value="{PAYMENT_DATE}">
<input type="hidden" name="data[cvv]" value="{CVV}">
{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>Payment Amount:</th>
  <td>${PAYMENT_AMOUNT}</td>
</tr>
<tr>
  <th>Payment Date:</th>
  <td>{PAYMENT_DATE}</td>
</tr>
<tr>
  <td>&nbsp;</td>
  <td><input type="submit" name="data[uap]" value="Edit"> <input type="submit" name="data[uap]" value="Confirm"></td>
</tr>
</table>
</form>