gistfile1.rhtml

<div id="login_form"><div id="login_form_inner">
	<img src="../images/credit_cards_48.png" alt="image" width="48" height="48" class="lockimg" />
	<div id="login_form_items">
		
  <% if @subscription %>
    <h2><input type="radio" name="paypal" value=" " <%= 'checked="checked"' unless @subscription.paypal? %>> Pay with a credit card</h2>
  <% end %>

	<p>
  <label>Name on Card</label><br />
  <%= text_field :creditcard, :first_name, :size => 20 %>
  <%= text_field :creditcard, :last_name, :size => 20 %></p>
  
  <p><label>Card Number</label><br />
  <%= text_field :creditcard, :number, :size => 20 %></p>

  <p><label>Type</label><br />
  <%= select :creditcard, :type, [['Visa', 'visa'], ['MasterCard', 'master'], ['American Express', 'american_express']] %></p>

  <p><label>Expiration</label><br />
  <%= select :creditcard, :month, (1 .. 12) %>
  <%= select :creditcard, :year, (Time.now.year .. 10.years.from_now.year) %></p>

  <p><label>CVV</label><br />
  <%= text_field :creditcard, :verification_value, :size => 4 %><br />
  <%= image_tag('cvv.gif', :size => '51x31', :align => 'top') %></p>

  <p><label>Address</label><br />
  <%= text_field :address, :address1 %><br/>
  <%= text_field :address, :address2 %></p>

  <p><label>City</label><br />
  <%= text_field :address, :city %></p>

  <p><label>State</label><br />
  <%= text_field :address, :state %></p>

  <label>Zip</label><br />
  <%= text_field :address, :zip %>

  <p><label>Country</label><br />
  <%= country_select :address, :country, ['United States', 'Canada'] %></p>

  <p><label>Phone</label><br />
  <%= text_field :address ,:phone %></p>

</div><br clear="all" />

	</div></div>

	<div id="signup_teaser"><div id="signup_teaser_inner">
	<img src="../images/questionmark_48.png" alt="image" width="48" height="48" class="signupimg" /><h3>Payment Information</h3>

	Fill out the payment information to the left for your membership. 
	<br clear="all" />
	</div></div><br clear="all" />

	<br />