<p class="InfoMessage">
	%%LNG_eSelectPlusDPPaymentIntro%%
</p>
<p class="ErrorMessage" style="display:%%GLOBAL_HideeSelectPlusDPError%%">
	%%LNG_eSelectPlusDPProcessingError%%<br />
	<strong>%%GLOBAL_eSelectPlusDPErrorMessage%%</strong>
</p>
<form action="%%GLOBAL_ShopPathSSL%%/checkout.php?action=process_payment" method="post" onsubmit="return check_eselectplusdp_payment_form()">
	<div class="FormContainer HorizontalFormContainer">
		<dl>
			<dt><span class="Required">*</span> %%LNG_eSelectPlusDPCreditCardNo%%:</dt>
			<dd>
				<input type="text" name="cc_num" id="cc_num" value="%%GLOBAL_eSelectPlusDPNum%%" size="30" class="Field200" />
				<br />
				<small>%%LNG_eSelectPlusDPCreditCardNoHelp%%</small>
			</dd>

			<dt><span class="Required">*</span> %%LNG_eSelectPlusDPExpirationDate%%:</dt>
			<dd>
				<select name="expMonth" id="expMonth">
					<option value=""></option>
					%%GLOBAL_eSelectPlusDPMonths%%
				</select>
				<select name="expYear" id="expYear">
					<option value=""></option>
					%%GLOBAL_eSelectPlusDPYears%%
				</select>
			</dd>

			<dt><span class="Required">*</span> %%LNG_eSelectPlusDPCreditCardCCV2%%:</dt>
			<dd id="CVV2Input">
				<input type="text" class="Textbox" name="cvd_value" id="cvd_value" value="%%GLOBAL_eSelectPlusDPCCV2%%" size="4" />
				&nbsp;<small><a href="#" id="CVV2Help">%%LNG_WhatsThis%%</a></small>
			</dd>

			<dt><span class="Required">*</span> %%LNG_eSelectPlusDPCardHoldersName%%:</dt>
			<dd><input type="text" name="cardholder" id="cardholder" value="%%GLOBAL_eSelectPlusDPCardHolderName%%" size="20" /></dd>

			<dt><span class="Required">*</span> %%LNG_eSelectPlusDPStreetName%%:</dt>
			<dd>
				<input type="text" name="avs_street_number" id="avs_street_number" value="%%GLOBAL_eSelectPlusDPBillStNum%%" size="20" class="Textbox Field45" />
				<input type="text" name="avs_street_name" id="avs_street_name" value="%%GLOBAL_eSelectPlusDPBillStName%%" size="20" class="Field200" />
				</dd>

			<dt><span class="Required">*</span> %%LNG_eSelectPlusDPZip%%:</dt>
			<dd><input type="text" name="avs_zipcode" id="avs_zipcode" value="%%GLOBAL_eSelectPlusDPBillZip%%" size="6" /></dd>

			<dt>&nbsp;&nbsp; %%LNG_eSelectPlusDPTotalAmount%%:</dt>
			<dd>
				<em class="ProductPrice">%%GLOBAL_OrderAmount%%</em>
			</dd>
		</dl>
		<p class="Submit">
			<input type="submit" value="%%LNG_eSelectPlusDPPayForOrder%%" />
		</p>
	</div>
</form>
%%Panel.eSelectPlusDPPaymentJavaScript%%