{% extends '::baseAjax.html.twig' %} 
{% block ajax_body %}
<style>
/*--CREDIT APPLICATION FORM--*/
#myModalForm .modal-footer{background: none;}
#myModalForm .table.credit-app-form{background: #fff;margin-bottom: 0;}
#myModalForm .modal-dialog{width:960px;margin: 30px auto;}
/*#myModalForm.modal.in .modal .modal-dialog .modal-content {width: 100%;}*/
.goldform{padding: 0 30px;}
.goldform table{border: none;}
.goldform label, .goldform table tr td {font: 12px robotomedium;color: #000;padding: 2px 0;border: none;}
.goldform input[type="text"]{display: inline-block;border: none;box-shadow: none;border-bottom: 1px solid #000;padding: 0;height: auto;line-height: 12px;font: 12px robotomedium;color: #000;}
.goldform .checkbox label{padding-left: 15px;}
.goldform .checkbox{margin-top: 10px !important;}
.goldform textarea{border: none;box-shadow: none;border-bottom: 2px solid #000;padding: 0;height:15px;line-height: 12px;width: 98%;resize: inherit;}
.goldform p{padding-top: 10px;font: 12px robotomedium;color: #000;}
.goldform table tr td table.terms-table p{padding: 10px 0;font-size: 14px;}
.goldform table tr td table.terms-table h4{font: 14px robotomedium;color: #000;padding: 10px 0;}
.goldform table tr td table.terms-table ul li{list-style: decimal;list-style-position: inside;}
.goldform table tr td table.terms-table ul li p{display: initial;padding-left: 5px;}
.goldform table tr td .checkbox label::before{width: 15px;height: 15px;}
.goldform table tr td .checkbox label::after{top: 1px;margin-left: -13px;}
.goldform .input-group{display: inline-block;}
.goldform .input-group .input-group-addon {padding: 0px 8px;background-color: transparent;border: none;display: inline-block;}

/*--CREDIT APPLICATION FORM--*/
</style>
<div aria-hidden="false" role="dialog" tabindex="-1" id="myModalForm" class="modal model-popup-black in" style="display: block;">
    <div class="modal-dialog modal-lg">
        <div class="modal-content">
            
            

             {{ form_start(credit_application_form, {'action': path('office_brain_cmsbundle_credit_application_form_save'), 'method': 'POST'}) }}
            <div id="print_div" class="modal-body">
                
                
                <div class="goldform">
                	<table width="100%" border="0">
				     <tbody>
				     <tr>
				         <td align="center" colspan="3"><img src="{{ ob_project_base_url~asset(ob_project_assets_base_url ~ 'images/goldstar/goldstar-logo-png.png')  }}"></td>
				     </tr>
				     <tr>
				         <td>
				            <table width="100%">
				             <tbody>
				             <tr>
				                <td align="right">CREDIT APPLICATION</td>
				                <td width="10%"></td>
				                <td width="35%">
				                	<label>  Date: </label> 
				                	{{ form_widget(credit_application_form.createDate,{'value':"now"|date("m/d/Y"),'attr':{'class':'form-control', 'style':'width:50%', 'placeholder':''}} ) }}
				                </td>
				             </tr>
				            </tbody>
				            </table> 
				         </td>
				     </tr>
				     <tr>
				        <td colspan="3">
				           <table width="100%" border="0">
				               <tbody>
				               <tr>
				                   <td width="50%">
					                   <label>1.Business Name:<span class="red">*</span></label> 
					                   {{ form_widget(credit_application_form.businessName,{'attr':{'class':'form-control', 'style':'width:75%', 'placeholder':''}} ) }}
				                   </td>
				                   <td width="50%">
					                   <label>2.dba:<span class="red">*</span></label> 
					                   {{ form_widget(credit_application_form.dba,{'attr':{'class':'form-control', 'style':'width:88%', 'placeholder':''}} ) }}
				                   </td>
				               </tr>
				           </tbody>
				           </table>
				        </td>
				     </tr>
				     <tr>
				        <td colspan="3">
				          <table width="100%">
				             <tbody>
				             <tr>
				                 <td width="30%">
					                 <label>3.Business Type:</label> 
					                 {{ form_widget(credit_application_form.businessType,{'attr':{'class':'form-control', 'style':'width:58%', 'placeholder':''}} ) }}
				                 </td>
				                 <td width="36%">
					                 <label> 4.Phone:<span class="red">*</span></label> 
{# 					                 <input type="text" style="width:72px" placeholder="" class="form-control">#}
{# 					                 <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					                 <input type="text" style="width:78px" placeholder="" class="form-control">#}
{# 					                 <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					                 <input type="text" style="width:80px" placeholder="" class="form-control">#}
					                 {{ form_widget(credit_application_form.phone,{'attr':{'class':'form-control js-phone','autocomplete':'off', 'style':'width:250px', 'placeholder':''}} ) }}
				                 </td>
				                 <td width="34%">
					                 <label> 5.Fax:</label> 
					                 {{ form_widget(credit_application_form.fax,{'attr':{'class':'form-control js-phone','autocomplete':'off', 'style':'width:243px', 'placeholder':''}} ) }}
				                 </td>
				             </tr>
				          </tbody>
				          </table>
				        </td>
				     </tr>
				     <tr>
				        <td colspan="3">
				          <table width="100%">
				            <tbody>
				            <tr>
				                <td>
				                   <table width="100%">
				                     <tbody>
				                     <tr>
				                         <td width="68%">
					                         <label>6.Address:<span class="red">*</span></label> 
					                         {{ form_widget(credit_application_form.address,{'attr':{'class':'form-control', 'style':'width:87%', 'placeholder':''}} ) }}
				                         </td>
				                         <td>
					                         <label>7. For past</label> 
					                         {{ form_widget(credit_application_form.pastYears,{'attr':{'class':'form-control', 'style':'width:40%', 'placeholder':''}} ) }}
					                         <label>year(s).</label>
				                         </td>
				                         <td width="5%"></td>
				                     </tr>
				                   </tbody>
				                   </table>
				                </td>
				            </tr>
				            <tr>
				                <td>
				                   <table width="100%">
				                     <tbody>
				                     <tr>
				                         <td width="15%"></td> 
				                         <td>(Street)</td>
				                     </tr>
				                   </tbody>
				                   </table>
				                </td>
				            </tr>
				            <tr>
				                <td>
				                   <table width="100%">
				                     <tbody>
				                     <tr>
				                         <td width="7%"></td> 
				                         <td width="52%">
				                         	{{ form_widget(credit_application_form.city,{'attr':{'class':'form-control', 'style':'width:32%', 'placeholder':''}} ) }}
				                         	{{ form_widget(credit_application_form.state,{'attr':{'class':'form-control', 'style':'width:32%', 'placeholder':''}} ) }}
				                         	{{ form_widget(credit_application_form.zipcode,{'attr':{'class':'form-control', 'style':'width:32%', 'placeholder':''}} ) }}
				                         </td>
				                         <td width="32%">
					                         <label>8. Date Established:<span class="red">*</span></label> 
					                         <div class="input-append date input-group date-block" id="datetimepicker20">
												{{ form_widget(credit_application_form.dateEstablished,{'attr':{'class':'form-control datepicker-color', 'style':'width:58%', 'data-format':'MM/dd/yyyy', 'placeholder':'', 'data-placement':'right', 'readonly':'readonly'}}) }}
						                    	<span class="add-on input-group-addon datepicker-color">
						                        	<i class="fa-calendar fa"></i>
						                        </span>
						                    </div>
				                         </td>
				                     </tr>
				                   </tbody>
				                   </table>
				                </td>
				            </tr>
				            <tr>
				                <td>
				                   <table width="100%">
				                     <tbody>
				                     <tr>
				                         <td width="8%"></td> 
				                         <td width="18.33%" align="center">(City)</td>
				                         <td width="18.33%" align="center">(State)</td>
				                         <td width="18.33%" align="center">(Zip Code)</td>
				                         <td width="37%"></td>
				                     </tr>
				                   </tbody>
				                   </table>
				                </td>
				            </tr>
				          </tbody>
				          </table>
				        </td>
				     </tr>
				     <tr>
				        <td colspan="3">
				          <table width="100%">
				             <tbody>
				             <tr>
				                 <td colspan="5">
					                 <label>9.Shipping Address:<span class="red">*</span></label> 
					                 {{ form_widget(credit_application_form.shippingAddrStreet,{'attr':{'class':'form-control', 'style':'width:21%', 'placeholder':''}} ) }}
					                 {{ form_widget(credit_application_form.shippingAddrCity,{'attr':{'class':'form-control', 'style':'width:21%', 'placeholder':''}} ) }}
					                 {{ form_widget(credit_application_form.shippingAddrState,{'attr':{'class':'form-control', 'style':'width:21%', 'placeholder':''}} ) }}
					                 {{ form_widget(credit_application_form.shippingAddrZipcode,{'attr':{'class':'form-control', 'style':'width:21%', 'placeholder':''}} ) }}
				                 </td>
				             </tr>
				             <tr>
				                 <td width="20%"></td>
				                 <td align="center">(Street)</td>
				                 <td align="center">(City)</td>
				                 <td align="center">(State)</td>
				                 <td align="center">(Zip Code)</td>
				             </tr>
				          </tbody>
				          </table>
				        </td>
				     </tr>
				     <tr>
				        <td colspan="3">
				          <table width="100%">
				            <tbody>
				            <tr>
				               <td width="36%">
					               <label>10.Fed Tax ID#:<span class="red">*</span></label> 
					               {{ form_widget(credit_application_form.fedTaxId,{'attr':{'class':'form-control', 'style':'width:66%', 'placeholder':''}} ) }}
				               </td>
				               <td>
					               <label>11. DUNS #:</label> 
					               {{ form_widget(credit_application_form.duns,{'attr':{'class':'form-control', 'style':'width:70%', 'placeholder':''}} ) }}
				               </td>
				               <td>
					               <label>12. ASI #:</label> 
					               {{ form_widget(credit_application_form.asi,{'attr':{'class':'form-control', 'style':'width:74%', 'placeholder':''}} ) }}
				               </td>
				            </tr>
				          </tbody>
				          </table>
				        </td>
				     </tr>
				     <tr>
				        <td colspan="3">
					        <label style="margin-right:5px;">13.Former Business Address (If less than 5 years)</label>
					        {{ form_widget(credit_application_form.formerBusinessAddress,{'attr':{'class':'form-control', 'style':'width:65%', 'placeholder':''}} ) }}
				        </td>
				     </tr>
				      <tr>
				        <td colspan="3">
				          <table width="100%">
				            <tbody>
				            <tr>
				               <td>
					               <label>14.Number of Employees:</label>
					               {{ form_widget(credit_application_form.numberOfEmployees,{'attr':{'class':'form-control', 'style':'width:43%', 'placeholder':''}} ) }}
				               </td>
				               <td>
					               <label>15. Est. Annual Sales: $ </label>
					               {{ form_widget(credit_application_form.estAnnualSales,{'attr':{'class':'form-control', 'style':'width:45%', 'placeholder':''}} ) }}
				               </td>
				               <td width="35%">
					               <label>16. Owner/Pres.: </label>
					               {{ form_widget(credit_application_form.owner,{'attr':{'class':'form-control', 'style':'width:64%', 'placeholder':''}} ) }}
				               </td>
				            </tr>
				          </tbody>
				          </table>
				        </td>
				     </tr>
				      <tr>
				        <td colspan="3">
				          <table width="100%">
				            <tbody>
				            <tr>
				               <td>
					               <label>17.AP Contact:</label> 
					               {{ form_widget(credit_application_form.apContact,{'attr':{'class':'form-control', 'style':'width:70%', 'placeholder':''}} ) }}
				               </td>
				               <td>
					               <label>18. Authorized Individual to issue P.O.'s: </label> 
					               {{ form_widget(credit_application_form.authorizedIndividualToIssuePo,{'attr':{'class':'form-control', 'style':'width:53%', 'placeholder':''}} ) }}
				               </td> 
				            </tr>
				          </tbody>
				          </table>
				        </td>
				     </tr>
				     <tr>
				        <td colspan="3">
				          <table width="100%">
				            <tbody><tr>
				               <td width="42%"><label>19.Has firm or its Principals ever been bankrupt?</label></td>
				               <td width="35%">
				                   <div style="float: left; width: 30%;text-align: center;" class="">
				                        {{ form_widget(credit_application_form.bankrupt,{'attr':{'style':'width:140%', 'placeholder':''}} ) }}
				                   </div>
				               </td> 
				               <td width="27%">
				               		<label>If Yes, Explain:</label>
				               </td> 
				            </tr>
				          </tbody></table>
				        </td>
				     </tr>
				     <tr>
				     	<td>
				     		{{ form_widget(credit_application_form.bankruptDetails,{'attr':{'class':'form-control', 'placeholder':''}} ) }}
				     	</td>
				     </tr>
				     <tr>
				        <td colspan="3"> 
				        	<label>20.TRADE REFERENCES:</label>
				        </td> 
				     </tr>
				      <tr>
				        <td colspan="3">
				          <table width="100%">
				            <tbody>
				            <tr>
				               <td width="67%">
					               <label>A.Name: </label>
					               {{ form_widget(credit_application_form.tradeReferenceName,{'attr':{'class':'form-control', 'style':'width:89%', 'placeholder':''}} ) }}
				               </td> 
				               <td width="33%">
					               <label>Contact:</label>
					               {{ form_widget(credit_application_form.tradeReferenceContact,{'attr':{'class':'form-control', 'style':'width:81%', 'placeholder':''}} ) }}
				               </td> 
				            </tr>
				          </tbody>
				          </table>
				        </td>
				     </tr>
				     <tr>
				        <td colspan="3">
				          <table width="100%">
				            <tbody>
				            <tr>
				               <td width="25%">
					               <label>Phone:</label> 
{# 					               <input type="text" style="width:47px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
									{{ form_widget(credit_application_form.tradeReferencePhone,{'attr':{'class':'form-control js-phone','autocomplete':'off', 'style':'width:143px', 'placeholder':''}} ) }}
				               </td>
				               <td width="23%">
					               <label>Fax:</label>
{# 					               <input type="text" style="width:47px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
					               {{ form_widget(credit_application_form.tradeReferenceFax,{'attr':{'class':'form-control js-phone','autocomplete':'off', 'style':'width:143px', 'placeholder':''}} ) }}
				               </td>
				               <td width="32%">
					               <label>Payment Terms:</label> 
					               {{ form_widget(credit_application_form.tradeReferencePaymentTerms,{'attr':{'class':'form-control', 'style':'width:62%', 'placeholder':''}} ) }}
				               </td>
				               <td width="20%">
					               <label>How Long?</label> 
					               {{ form_widget(credit_application_form.tradeReferenceHowLong,{'attr':{'class':'form-control', 'style':'width:58%', 'placeholder':''}} ) }}
				               </td>
				            </tr>
				          </tbody>
				          </table>
				        </td>
				     </tr>
				     <tr>
				        <td colspan="3">
				          <table width="100%">
				           <tbody>
				           <tr>
				               <td width="67%">
					               <label>B.Name: </label>
					               {{ form_widget(credit_application_form.tradeReferenceName2,{'attr':{'class':'form-control', 'style':'width:89%', 'placeholder':''}} ) }}
				               </td> 
				               <td width="33%">
					               <label>Contact:</label>
					               {{ form_widget(credit_application_form.tradeReferenceContact2,{'attr':{'class':'form-control', 'style':'width:81%', 'placeholder':''}} ) }}
				               </td> 
				            </tr>
				          </tbody>
				          </table>
				        </td>
				     </tr>
				      <tr>
				        <td colspan="3">
				          <table width="100%">
				            <tbody>
				            <tr>
				               <td width="25%">
					               <label>Phone:</label> 
{# 					               <input type="text" style="width:47px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
					               {{ form_widget(credit_application_form.tradeReferencePhone2,{'attr':{'class':'form-control js-phone','autocomplete':'off', 'style':'width:143px', 'placeholder':''}} ) }}
				               </td>
				               <td width="23%">
					               <label>Fax:</label>
{# 					               <input type="text" style="width:47px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
					               {{ form_widget(credit_application_form.tradeReferenceFax2,{'attr':{'class':'form-control js-phone','autocomplete':'off', 'style':'width:143px', 'placeholder':''}} ) }}
				               </td>
				               <td width="32%">
					               <label>Payment Terms:</label> 
					               {{ form_widget(credit_application_form.tradeReferencePaymentTerms2,{'attr':{'class':'form-control', 'style':'width:62%', 'placeholder':''}} ) }}
				               </td>
				               <td width="20%">
					               <label>How Long?</label> 
					               {{ form_widget(credit_application_form.tradeReferenceHowLong2,{'attr':{'class':'form-control', 'style':'width:58%', 'placeholder':''}} ) }}
				               </td>
				            </tr>
				          </tbody>
				          </table>
				        </td>
				     </tr>
				     <tr>
				        <td colspan="3">
				          <table width="100%">
				            <tbody>
				            <tr>
				               <td width="67%">
					               <label>C.Name: </label>
					               {{ form_widget(credit_application_form.tradeReferenceName3,{'attr':{'class':'form-control', 'style':'width:89%', 'placeholder':''}} ) }}
				               </td> 
				               <td width="33%">
					               <label>Contact:</label>
					               {{ form_widget(credit_application_form.tradeReferenceContact3,{'attr':{'class':'form-control', 'style':'width:81%', 'placeholder':''}} ) }}
				               </td> 
				            </tr>
				          </tbody>
				          </table>
				        </td>
				     </tr>
				      <tr>
				        <td colspan="3">
				          <table width="100%">
				            <tbody>
				            <tr>
				               <td width="25%">
					               <label>Phone:</label> 
{# 					               <input type="text" style="width:47px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
					               {{ form_widget(credit_application_form.tradeReferencePhone3,{'attr':{'class':'form-control js-phone','autocomplete':'off', 'style':'width:143px', 'placeholder':''}} ) }}
				               </td>
				               <td width="23%">
					               <label>Fax:</label>
{# 					               <input type="text" style="width:47px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
					               {{ form_widget(credit_application_form.tradeReferenceFax3,{'attr':{'class':'form-control js-phone','autocomplete':'off', 'style':'width:143px', 'placeholder':''}} ) }}
				               </td>
				               <td width="32%">
					               <label>Payment Terms:</label> 
					               {{ form_widget(credit_application_form.tradeReferencePaymentTerms3,{'attr':{'class':'form-control', 'style':'width:62%', 'placeholder':''}} ) }}
				               </td>
				               <td width="20%">
					               <label>How Long?</label> 
					               {{ form_widget(credit_application_form.tradeReferenceHowLong3,{'attr':{'class':'form-control', 'style':'width:58%', 'placeholder':''}} ) }}
				               </td>
				            </tr>
				          </tbody>
				          </table>
				        </td>
				     </tr>
				     <tr>
				        <td colspan="3">
				          <table width="100%">
				            <tbody>
				            <tr>
				               <td width="67%">
					               <label>D.Name: </label>
					               {{ form_widget(credit_application_form.tradeReferenceName4,{'attr':{'class':'form-control', 'style':'width:89%', 'placeholder':''}} ) }}
				               </td> 
				               <td width="33%">
					               <label>Contact:</label>
					               {{ form_widget(credit_application_form.tradeReferenceContact4,{'attr':{'class':'form-control', 'style':'width:81%', 'placeholder':''}} ) }}
				               </td> 
				            </tr>
				          </tbody>
				          </table>
				        </td>
				     </tr>
				      <tr>
				        <td colspan="3">
				          <table width="100%">
				            <tbody>
				            <tr>
				               <td width="25%">
					               <label>Phone:</label> 
{# 					               <input type="text" style="width:47px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
					               {{ form_widget(credit_application_form.tradeReferencePhone4,{'attr':{'class':'form-control js-phone','autocomplete':'off', 'style':'width:143px', 'placeholder':''}} ) }}
				               </td>
				               <td width="23%">
					               <label>Fax:</label>
{# 					               <input type="text" style="width:47px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
					               {{ form_widget(credit_application_form.tradeReferenceFax4,{'attr':{'class':'form-control js-phone','autocomplete':'off', 'style':'width:143px', 'placeholder':''}} ) }}
				               </td>
				               <td width="32%">
					               <label>Payment Terms:</label> 
					               {{ form_widget(credit_application_form.tradeReferencePaymentTerms4,{'attr':{'class':'form-control', 'style':'width:62%', 'placeholder':''}} ) }}
				               </td>
				               <td width="20%">
					               <label>How Long?</label> 
					               {{ form_widget(credit_application_form.tradeReferenceHowLong4,{'attr':{'class':'form-control', 'style':'width:58%', 'placeholder':''}} ) }}
				               </td>
				            </tr>
				          </tbody>
				          </table>
				        </td>
				     </tr>
				     <tr>
				        <td colspan="3"> <label>21.BANK REFERENCE:</label> </td> 
				     </tr>
				     <tr>
				        <td colspan="3">
				          <table width="100%">
				            <tbody>
				            <tr>
				               <td width="67%">
					               <label>Name: </label>
					               {{ form_widget(credit_application_form.bankReferenceName,{'attr':{'class':'form-control', 'style':'width:91%', 'placeholder':''}} ) }}
				               </td> 
				               <td width="33%">
					               <label>Account #: </label>
					               {{ form_widget(credit_application_form.bankReferenceAccountNo,{'attr':{'class':'form-control', 'style':'width:74%', 'placeholder':''}} ) }}
				               </td> 
				            </tr>
				          </tbody>
				          </table>
				        </td>
				     </tr>
				     <tr>
				        <td colspan="3">
				          <table width="100%">
				            <tbody><tr>
				               <td width="25%">
					               <label>Phone:</label> 
{# 					               <input type="text" style="width:47px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
					               {{ form_widget(credit_application_form.bankReferencePhone,{'attr':{'class':'form-control js-phone','autocomplete':'off', 'style':'width:143px', 'placeholder':''}} ) }}
				               </td>
				               <td width="23%">
					               <label>Fax:</label>
{# 					               <input type="text" style="width:47px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
					               {{ form_widget(credit_application_form.bankReferenceFax,{'attr':{'class':'form-control js-phone','autocomplete':'off', 'style':'width:143px', 'placeholder':''}} ) }}
				               </td>	
				               <td width="52%">
					               <label>Contact:</label> 
					               {{ form_widget(credit_application_form.bankReferenceContact,{'attr':{'class':'form-control', 'style':'width:87%', 'placeholder':''}} ) }}
				               </td>
				            </tr>
				          </tbody></table>
				        </td>
				     </tr>
				     <tr>
				        <td colspan="3"> 
					        <label>22. LOANSs: </label> 
{# 					        <input type="text" style="width:90%" placeholder="" class="form-control">#}
				        </td> 
				     </tr>
				     <tr>
				        <td colspan="3">
				          <table width="100%">
				            <tbody>
				            <tr>
				               <td width="67%">
					               <label>Name: </label>
					               {{ form_widget(credit_application_form.loanName,{'attr':{'class':'form-control', 'style':'width:91%', 'placeholder':''}} ) }}
				               </td> 
				               <td width="33%">
					               <label>Account #: </label>
					               {{ form_widget(credit_application_form.loanAccountNo,{'attr':{'class':'form-control', 'style':'width:74%', 'placeholder':''}} ) }}
				               </td> 
				            </tr>
				          </tbody>
				          </table>
				        </td>
				     </tr>
				     <tr>
				        <td colspan="3">
				          <table width="100%">
				            <tbody>
				            <tr>
				               <td width="25%">
					               <label>Phone:</label> 
{# 					               <input type="text" style="width:47px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
					               {{ form_widget(credit_application_form.loanPhone,{'attr':{'class':'form-control js-phone','autocomplete':'off', 'style':'width:143px', 'placeholder':''}} ) }}
				               </td>
				               <td width="23%">
					               <label>Fax:</label>
{# 					               <input type="text" style="width:47px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
{# 					               <sub style="vertical-align: middle;padding: 0px 5px;">-</sub>#}
{# 					               <input type="text" style="width:48px" placeholder="" class="form-control">#}
					               {{ form_widget(credit_application_form.loanFax,{'attr':{'class':'form-control js-phone','autocomplete':'off', 'style':'width:143px', 'placeholder':''}} ) }}
				               </td>
				               <td width="20%">
					               <label>Contact:</label> 
					               {{ form_widget(credit_application_form.loanContact,{'attr':{'class':'form-control', 'style':'width:65%', 'placeholder':''}} ) }}
				               </td>
				               <td width="32%">
					               <label>Approximate Balance: $_</label>
					               {{ form_widget(credit_application_form.loanApproxBalance,{'attr':{'class':'form-control', 'style':'width:43%', 'placeholder':''}} ) }}
				               </td>
				            </tr>
				          </tbody>
				          </table>
				        </td>
				     </tr>
				     <tr>
				        <td colspan="6">
				        <p>The undersigned warrants that the above information is true and correct and has read, understands and agrees with separate Terms and Conditions listed on the reverse side of this application. As an inducement to grant credit, the undersigned agrees to the need for verification of all information on this application and authorizes, and releases all banks, businesses and persons identified on this application to furnish any and all information requested by Goldstar/National Design Corporation or its representative, by telephone or written correspondence. As an inducement to grant credit, the undersigned agrees that Goldstar/National Design Corporation is right to obtain the credit history of the undersigned and authorizes the release of such information by signature here.</p>
				        </td>
				     </tr>
				     <tr>
				        <td colspan="6">
				          <table width="100%">
				            <tbody>
				            <tr>
				               <td width="55%">
					               <label>23.Signature:</label>
					               <input type="text" style="width:82%" placeholder="" class="form-control">
				               </td>
				               <td width="45%">
					               <label>Title:</label>
					               {{ form_widget(credit_application_form.title,{'attr':{'class':'form-control', 'style':'width:90%', 'placeholder':''}} ) }}
				               </td>
				            </tr>
				          </tbody>
				          </table>
				        </td>
				     </tr>
				     <tr>
				        <td style="padding:10px;" colspan="6">
				           <table width="100%" style="padding:5px;border: 1px solid #000;">
				             <tbody>
				             <tr>
				                 <td width="50%" style="padding:5px 0px 15px 10px;">
					                 <label>Line of Credit Requested: $ </label>
					                 {{ form_widget(credit_application_form.lineOfCreditRequested,{'attr':{'class':'form-control', 'style':'width:59%', 'placeholder':''}} ) }}
				                 </td>
				                 <td width="50%" style="padding:5px 0px 15px 10px;">
					                 <label>Present Balance: $ </label>
					                 {{ form_widget(credit_application_form.presentBalance,{'attr':{'class':'form-control', 'style':'width:72%', 'placeholder':''}} ) }}
				                 </td>
				             </tr>
				           </tbody>
				           </table>
				        </td>
				     </tr>
				       
				       <tr><td><table width="100%" class="terms-table">
				     <tbody><tr>
				        <td align="center" colspan="6"><br><br><br><br><br><h4>TERMS AND CONDITIONS</h4></td>
				     </tr>
				     <tr>
				        <td colspan="6"><p>Applicant agrees the extension of credit by seller shall be subject to and in consideration of the following terms and conditions:</p></td>
				     </tr>
				     
				     <tr>
				        <td colspan="6">
				            <ul>
				            <li><p>Payment of all amounts due shall be made no later than the due date indicated on the invoice.</p></li>
				            <li><p>NSF checks will be subject to a $25.00 charge.</p></li>
				            <li><p>Customer must notify Goldstar/National Design of any dispute within 60 days of receipt of merchandise.</p></li>
				            <li><p>Product returns must have a Return Authorization issued by Customer Service Dept. and are subject to prepaid shipping requirements. Shipments without Return Authorization or shipped collect will be refused. A 15% restocking fee will be charged for all returns on non-defective merchandise.</p></li>
				            <li><p>Cancellations must be made within 72 hours of placing order. A cancellation fee of $50 plus any production costs incurred will be charged.</p></li>
				            <li><p>A rush charge of 10% or a flat rate of $25.00 will be added if product is to be delivered in less than standard quoted lead-time. </p></li>
				            <li><p>In consideration of credit extended by Goldstar/National Design, I/We agree to pay for all cost of goods, merchandise, freight and interest supplied to the business named on the reverse side. If this account is placed with a collection agency or an attorney, I/We agree to pay all costs of collection including reasonable attorney’s fees.</p></li>
				            <li><p>This agreement shall be governed and construed in accordance with the laws of the State of California, and any disputes shall be settled in the County of San Diego, California. </p></li>
				            <li><p>In the event of sale of business entity, I/We will notify Goldstar/National Design in writing no less than 60 days prior to closing. All outstanding balances are to be cleared at time of closing unless Goldstar/National Design Corp has accepted prior arrangements in writing.</p></li>
				            <li><p>I/We authorize Goldstar/National Design to investigate credit/bank references and obtain necessary credit reports to determine the extension of credit to our company and to report credit experience with our company to credit reporting agencies. Phone: 800-366-7367.</p></li>
				            </ul>
				        </td>
				     </tr>
				     <tr>
				        <td colspan="6"><p> Please email or fax back completed form to:<br> <a href="javascript:void(0);">GoldstarPay@GoldstarPens.com</a> or fax to 858-385-5808, Attn: Sara Bumb.</p></td>
				     </tr>
				       </tbody></table></td></tr>
				   </tbody></table>
				  </div>




 			</div>
 			
 			
 			
 		{{ form_end(credit_application_form) }}
        </div>
    </div>
</div>



{% endblock ajax_body %}