{assign var="billingData" value=$paymentProfile->billingData}
<script language="javascript" type="text/javascript">
var countriesStates = {$countries_states};
{literal}
$(document).ready(function(){
setCountriesStates(
{/literal}
"#billing_country", "{$billingData->countryId|htmlspecialchars}",
"#billing_state", "{$billingData->stateId|htmlspecialchars}",
"#billing_province", "{$billingData->province|htmlspecialchars}",
countriesStates
{literal}
);
});
{/literal}
</script>
<div class="field">
<label for="name">{$msg.billing.friendly_name}</label>
<div><input id="name" name="form[name]" type="text" value="{$paymentProfile->name|htmlspecialchars}"/></div>
</div>
<div class="field required first">
<label for="billing_first_name">{$msg.billing.first_name}</label>
<div><input id="billing_first_name" maxlength="30" type="text" name="form[first_name]" value="{$billingData->firstName|htmlspecialchars}" /></div>
</div>
<div class="field required">
<label for="billing_last_name">{$msg.billing.last_name}</label>
<div><input id="billing_last_name" maxlength="30" type="text" name="form[last_name]" value="{$billingData->lastName|htmlspecialchars}" /></div>
</div>
<div class="field required">
<label for="billing_address_line1">{$msg.billing.address_line1}</label>
<div><input id="billing_address_line1" maxlength="30" type="text" name="form[address1]" value="{$billingData->addressLine1|htmlspecialchars}" /></div>
</div>
{if $FormsBillingAddressLine2 != "Invisible"}
<div class="field{if $FormsBillingAddressLine2 == "Required"} required{/if}">
<label for="billing_address_line2">{$msg.billing.address_line2}</label>
<div><input id="billing_address_line2" maxlength="30" type="text" name="form[address2]" value="{$billingData->addressLine2|htmlspecialchars}"/></div>
</div>
{else}
<input id="billing_address_line2" type="hidden" name="form[address2]" value="{$billingData->addressLine2|htmlspecialchars}"/>
{/if}
<div class="field required">
<label for="billing_city">{$msg.billing.city}</label>
<div><input id="billing_city" maxlength="20" type="text" name="form[city]" value="{$billingData->city|htmlspecialchars}"/></div>
</div>
<div id="billing_country" class="field required">
<label for="billing_country_select">{$msg.billing.country}</label>
<div><select id="billing_country_select" name="form[country]"></select></div>
</div>
<div id="billing_state" class="field required invisible">
<label for="billing_state_select">{$msg.billing.state_province}</label>
<div>
<select id="billing_state_select" name="form[state]"></select>
</div>
</div>
<div id="billing_province" class="field required invisible">
<label for="billing_province_input">{$msg.billing.state_province}</label>
<div><input id="billing_province_input" maxlength="2" type="text" name="form[province]" value="{$billingData->province}"/></div>
</div>
<div class="field required">
<label for="billing_postal_code">{$msg.billing.postal_code}</label>
<div><input id="billing_postal_code" maxlength="10" type="text" name="form[zip]" value="{$billingData->zip|htmlspecialchars}"/></div>
</div>
{if $FormsBillingPhone != "Invisible"}
<div class="field{if $FormsBillingPhone == "Required"} required{/if}">
<label for="billing_phone_number">{$msg.billing.phone_number}</label>
<div><input id="billing_phone_number" maxlength="14" type="text" name="form[phone]" value="{$billingData->phone|htmlspecialchars}"/></div>
</div>
{else}
<input id="billing_phone_number" type="hidden" name="form[phone]" value="{$billingData->phone|htmlspecialchars}"/>
{/if}
<div class="field required">
<label for="cc_number">{$msg.billing.cc_number}</label>
<div><input id="cc_number" name="form[cc_number]" type="text" autocomplete="off"/></div>
</div>
<div class="field required">
<label>{$msg.billing.cc_expiration_date}</label>
<div>
<select class="select-expiration-month" name="form[cc_expiration_month]">
{foreach from=$cc_expiration_months key="key" item="month"}
<option value="{$key}" {if $billingData->ccExpirationMonth == $key}selected="selected"{/if}>{$month}</option>
{/foreach}
</select>
<select class="select-expiration-year" name="form[cc_expiration_year]">
{foreach from=$cc_expiration_years key="key" item="year"}
<option value="{$year}"{if $billingData->ccExpirationYear == substr($year, 2, 2) || $billingData->ccExpirationYear == $year} selected="selected"{/if}>{$year}</option>
{/foreach}
</select>
</div>
</div>
<div class="field">
<label for="is_primary">{$msg.account.set_primary_payment_profile}</label>
<div style="padding:5px 0px 0px;"><input style="margin-left:10px;" type="checkbox" id="is_primary" name="form[is_primary]" value="1" {if $paymentProfile->isPrimary}checked="checked"{/if}></div>
</div>