@extends($activeTemplate . 'layouts.master')
@section('content')
    @php
        $pageTitle = $pageTitle . ': NMI';
    @endphp
    <div class="row dashboard-widget-wrapper justify-content-center">
        <div class="col-md-12">
            <form role="form" id="payment-form" method="{{ $data->method }}" class="disableSubmission" action="{{ $data->url }}">
                @csrf
                <div class="row">
                    <div class="col-md-12">
                        <label class="form--label">@lang('Card Number')</label>
                        <div class="input-group input-with-text">
                            <input type="tel" class="form--control" name="billing-cc-number"
                                autocomplete="off" value="{{ old('billing-cc-number') }}" required autofocus />
                            <span class="input-group-text"><i class="fa fa-credit-card"></i></span>
                        </div>
                    </div>
                </div>

                <div class="row mt-4">
                    <div class="col-md-6">
                        <label class="form--label">@lang('Expiration Date')</label>
                        <input type="tel" class="form--control" name="billing-cc-exp"
                            value="{{ old('billing-cc-exp') }}" placeholder="e.g. MM/YY" autocomplete="off" required />
                    </div>
                    <div class="col-md-6 ">
                        <label class="form--label">@lang('CVC Code')</label>
                        <input type="tel" class="form--control" name="billing-cc-cvv"
                            value="{{ old('billing-cc-cvv') }}" autocomplete="off" required />
                    </div>
                </div>
                <br>
                <button class="btn btn--base w-100" type="submit"> @lang('Submit')</button>
            </form>
        </div>
    </div>
@endsection