moodle/enrol/authorize/enrol.html

<p align="center"><?php if (!empty($this->ccerrormsg)) { formerr($this->ccerrormsg); } ?></p>

<div align="center">

<p><?php print_string("paymentrequired") ?></p>
<p><b><?php echo get_string("cost").": $curcost[currency]  $curcost[cost]"; ?></b></p>
<p><?php print_string("paymentinstant") ?></p>

<form name="form" method="post" action="enrol.php" autocomplete="off">
<input type="hidden" name="id" value="<?php p($course->id) ?>" />
<table align="center" width="100%" border=0>
<tr>
  <td align="right"><?php print_string("ccno", "enrol_authorize") ?>: </td>
  <td align="left"><input type="text" name="cc" size="16" value="<?php p($form->cc) ?>"  /></td>
</tr>
<tr>
  <td align="right"><?php print_string("nameoncard", "enrol_authorize") ?>: </td>
  <td align="left"><input type="text" name="ccfirstname" size="8" value="<?php p($userfirstname) ?>"  />
  <input type="text" name="cclastname" size="8" value="<?php p($userlastname) ?>"  /></td>
</tr>
<tr>
  <td align="right"><?php print_string("ccexpire", "enrol_authorize") ?>: </td>
  <td align="left"><?php
  for ($i=1; $i<=12; $i++) {
      $months[$i] = userdate(gmmktime(12,0,0,$i,1,2000), "%B");
  }
  choose_from_menu($months, 'ccexpiremm', $form->ccexpiremm);
  $nowdate = getdate();
  $nowyear = $nowdate["year"]-1;
  for ($i=$nowyear; $i<=$nowyear+11; $i++) {
      $years[$i] = $i;
  }
  choose_from_menu($years, 'ccexpireyyyy', $form->ccexpireyyyy);
  ?></td>
</tr>
<tr>
  <td align="right"><?php print_string("cctype", "enrol_authorize") ?>: </td>
  <td align="left"><?php
  $CCTYPES = array(
    'mcd' => 'Master Card', 'vis' => 'Visa',        'amx' => 'American Express',
    'dsc' => 'Discover',    'dnc' => 'Diners Club', 'jcb' => 'JCB',
    'swi' => 'Switch',      'dlt' => 'Delta',       'enr' => 'EnRoute'
  );
  choose_from_menu($CCTYPES, 'cctype', $form->cctype);
  ?>
</td>
</tr>
<tr>
  <td align="right"><?php print_string("ccvv", "enrol_authorize") ?>: </td>
  <td align="left"><input type="text" name="cvv" size="4" maxlength="4" value="<?php p($form->cvv) ?>" />
  <?php helpbutton('', '', 'enrol_authorize', true, 'cvv', get_string('ccvvhelp', 'enrol_authorize')); ?></td>
</tr>
<tr>
  <td align="right"><?php print_string("zipcode", "enrol_authorize") ?>: </td>
  <td align="left"><input type="text" name="cczip" size="5" value="<?php p($form->cczip) ?>" /></td>
</tr>
</table>
<input type="submit" value="<?php print_string("sendpaymentbutton", "enrol_authorize") ?>">
</form>

</div>