<?php
$page_title = "新規カード申請（住所入力）";
include_once('template/base_head.php');
?>
			<!-- サイドバー -->
			<aside id="colLeft">
				<h1><a href=""><img src="img/logo.png" alt="iWallet"></a></h1>
				<div class="aside-heading">
					&nbsp;
				</div>
				&nbsp;
			</aside>
			<!-- /サイドバー -->
			<!-- メインカラム -->
			<div id="colMain">
				<div class="mainIn">
					<?php include_once('template/base_nav.php'); ?>
					<article>
						<div class="article-heading">
							<h2><?php echo $page_title; ?></h2>
						</div>
						<?php $this -> echoMessage(); ?>
						<form id="acForm" action="" method="post" enctype="multipart/form-data">
							<table class="table col bdr default odd w50p fontXS m_auto mb20">
								<colgroup>
									<col class="w40p">
									<col class="w60p">
								</colgroup>
								<tr>
									<th>口座番号</th>
									<td><?php $this -> echoUserAccount(); ?></td>
								</tr>
								<tr>
									<th>アカウント名</th>
									<td><?php $this -> echoUserName(); ?></td>
								</tr>
								<tr>
									<th>氏名</th>
									<td><?php $this -> echoFirstName() ?> <?php $this -> echoLastName() ?></td>
								</tr>
								<tr>
									<th>郵送先国</th>
									<td>
										<select id="country" name="country">
											<?php $this -> dispHTMLCountry(); ?>
										</select>
									</td>
								</tr>
								<tr>
									<th>郵送先県・州</th>
									<td><input type="text" id="state" name="state" value="<?php $this -> echoState(); ?>" /></td>
								</tr>
								<tr>
									<th>郵送先市区町村</th>
									<td><input type="text" id="city" name="city" value="<?php $this -> echoCity(); ?>" /></td>
								</tr>
								<tr>
									<th>郵送先ご住所</th>
									<td><input type="text" id="address" name="address" value="<?php $this -> echoAddress(); ?>" /></td>
								</tr>
								<tr>
									<th>郵便番号</th>
									<td><input type="text" id="zip_code" name="zip_code" value="<?php $this -> echoZipCode(); ?>" /></td>
								</tr>
								<tr>
									<th>電話番号</th>
									<td><input type="text" id="tel" name="tel" value="<?php $this -> echoTel(); ?>" /></td>
								</tr>
							</table>
							<p class="calign">
								<a href="#" id="btnCreate" class="btn bg-default">&laquo; 戻る</a>&emsp;
								<input type="button" id="btnConfirm" value="確認画面へ" class="btn bg-grad px120 hi25">
							</p>

							<input type="hidden" value="card_apply" name="action" />
							<input type="hidden" id="type" name="type" />
							<input type="hidden" id="d_id" name="d_id" />
							<input type="hidden" id="user_account" name="user_account" value="<?php $this -> echoUserAccount(); ?>" />
							
							<!-- Language Transition Data (Anton) 04/22/2016 -->
							<input class="lang-trans-data" type="hidden" id="lang_data_action" value="/en/card_apply"/>
							<input class="lang-trans-data" type="hidden" id="lang_data_type" value="input"/>
							<input class="lang-trans-data" type="hidden" id="lang_data_form" value="#acForm"/>
							<!-- /Language Transition Data -->
						</form>

						<div class="article-bottom">
						</div>
					</article>
				</div>
			</div>
			<!-- /メインカラム -->
		</div>
		<?php include_once('template/base_foot.php'); ?>
	</div>
	<script src="js/card_apply.js"></script>
</body>
</html>
