Profile Nickname:
(used only to identify this profile at checkout)
{{ form_errors(form.nickname) }}
{{ form_widget(form.nickname) }} | First/Last Name:
(as it appears on card)
{{ form_errors(form.nameoncard) }}
{{ form_widget(form.nameoncard) }}
{{ form_errors(form.lnameoncard) }}
{{ form_widget(form.lnameoncard) }}
|
Billing Address: |
ATTN:(optional, used when you ship to this address) {{ form_errors(form.add2) }}{{ form_widget(form.add2) }} |
Address: {{ form_errors(form.add1) }}{{ form_widget(form.add1) }} |
City: {{ form_errors(form.city) }}{{ form_widget(form.city) }} |
State: {{ form_errors(form.state) }}{{ form_widget(form.state) }} |
Zip Code: {{ form_errors(form.zip) }}{{ form_widget(form.zip) }} |
Card Number: |
{{ form_errors(form.cc1) }}
{{ form_widget(form.cc1) }}
- |
{{ form_errors(form.cc2) }}
{{ form_widget(form.cc2) }}
- |
{{ form_errors(form.cc3) }}
{{ form_widget(form.cc3) }}
- |
{{ form_errors(form.cc4) }}
{{ form_widget(form.cc4) }}
|
|
EXP Date:
(EX 02 16) = Feb 2016
| Card Type:
(choose one) |
MM / | YY |
{{ form_errors(form.ccexpmo) }}
{{ form_widget(form.ccexpmo) }} |
{{ form_errors(form.ccexpyr) }}
{{ form_widget(form.ccexpyr) }} |
|
{{ form_errors(form.cardtype) }}
{{ form_widget(form.cardtype) }} |
CVV Code (3-4 digits in signature strip) |
{{ form_errors(form.cvv) }}
{{ form_widget(form.cvv) }} |
{{ form_widget(form.Save) }}
{{ form_end(form) }}