Credit/Debit Card Payment

Please fill out your payment information below. NOTE: We will attempt to bill <%= number_to_currency(Fe::Application::COST) %> to your credit card immediately when you press the 'Submit' button below.

Billing Address

First Name <%= text_field :payment, :first_name %>

Last Name <%= text_field :payment, :last_name %>

Address <%= text_field :payment, :address %>

City <%= text_field :payment, :city %>

State <%= select :payment, :state, State::NAMES, {:include_blank => true} %>

Zip Code <%= text_field :payment, :zip, {:size => "5"} %>

Card Information

Credit Card Number <%= text_field :payment, :card_number, {:size => "18", :maxlength => "16"} %> <%= image_tag "/images/cc_visa_on.gif", :class => "cc_type", :id => "cc_visa" %> <%= image_tag "/images/cc_master_on.gif", :class => "cc_type", :id => "cc_master" %> <%= image_tag "/images/cc_american_express_on.gif", :class => "cc_type", :id => "cc_american_express" %> <%= image_tag "/images/cc_discover_on.gif", :class => "cc_type", :id => "cc_discover" %> Invalid card number <%= hidden_field :payment, :card_type %>

Expiration Date <%= select :payment, :expiration_month, ['01', '02', '03', '04', '05', '06', '07', '08', '09', '10', '11', '12'], {:include_blank => true} %> <%= select :payment, :expiration_year, ((Time.now.year)..(Time.now.year+8)).to_a.map(&:to_s), {:include_blank => true} %>

Security Code (3-4 digit code on back of card) <%= text_field :payment, :security_code, {:size => "9", :maxlength => "5"} %>

<%= submit_tag "Submit Payment", :class => 'submit_payment', 'data-url' => fe_application_payments_path(@application) %>