{% extends 'CPPViawestPortalBundle:Default:base.html.twig' %} {% block title %}Account - Add Billing Profile{% endblock %} {% block pagecontent %}

Add a Billing Profile:


{% if data.msg is defined %} {{ data.msg }}
{% endif %} {% if data.msg2 is defined %}

{{ data.msg2 }}

{% endif %}
{{ form_start(form, { 'attr': {'name': 'details'} }) }} {{ form_errors(form) }}
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) }}
{% endblock %}