<h2><tmpl_var name="list_head_txt"></h2>
<p><tmpl_var name="list_desc_txt"></p>

<div class="panel panel_client">

  <div class="pnl_formsarea">
    <fieldset class="inlineLabels"><legend>Address</legend>
      <div class="ctrlHolder">
      	<label for="company_name">{tmpl_var name='company_name_txt'}</label>
        <input name="company_name" id="company_name" value="{tmpl_var name='company_name'}" size="30" maxlength="255" type="text" class="textInput" />
	  </div>
      <div class="ctrlHolder">
      	<label for="contact_name">{tmpl_var name='contact_name_txt'}*</label>
        <input name="contact_name" id="contact_name" value="{tmpl_var name='contact_name'}" size="30" maxlength="255" type="text" class="textInput" />
			</div>
	  <div class="ctrlHolder">
      	<label for="customer_no">{tmpl_var name='customer_no_txt'}</label>
        {tmpl_var name='customer_no'}
	  </div>
      <div class="ctrlHolder">
      	<label for="street">{tmpl_var name='street_txt'}</label>
        <input name="street" id="street" value="{tmpl_var name='street'}" size="30" maxlength="255" type="text" class="textInput" />
			</div>
      <div class="ctrlHolder">
      	<label for="zip">{tmpl_var name='zip_txt'}</label>
        <input name="zip" id="zip" value="{tmpl_var name='zip'}" size="10" maxlength="255" type="text" class="textInput" />
			</div>
      <div class="ctrlHolder">
      	<label for="city">{tmpl_var name='city_txt'}</label>
        <input name="city" id="city" value="{tmpl_var name='city'}" size="30" maxlength="255" type="text" class="textInput" />
			</div>
      <div class="ctrlHolder">
      	<label for="state">{tmpl_var name='state_txt'}</label>
        <input name="state" id="state" value="{tmpl_var name='state'}" size="30" maxlength="255" type="text" class="textInput" />
			</div>
      <div class="ctrlHolder">
      	<label for="country">{tmpl_var name='country_txt'}</label>
        <select name="country" id="country" class="selectInput withicons">
					{tmpl_var name='country'}
				</select>
      </div>
      <div class="ctrlHolder">
      	<label for="telephone">{tmpl_var name='telephone_txt'}</label>
        <input name="telephone" id="telephone" value="{tmpl_var name='telephone'}" size="30" maxlength="255" type="text" class="textInput" />
			</div>
      <div class="ctrlHolder">
      	<label for="mobile">{tmpl_var name='mobile_txt'}</label>
        <input name="mobile" id="mobile" value="{tmpl_var name='mobile'}" size="30" maxlength="255" type="text" class="textInput" />
			</div>
      <div class="ctrlHolder">
      	<label for="fax">{tmpl_var name='fax_txt'}</label>
        <input name="fax" id="fax" value="{tmpl_var name='fax'}" size="30" maxlength="255" type="text" class="textInput" />
			</div>
      <div class="ctrlHolder">
      	<label for="email">{tmpl_var name='email_txt'}</label>
        <input name="email" id="email" value="{tmpl_var name='email'}" size="30" maxlength="255" type="text" class="textInput" />
			</div>
      <div class="ctrlHolder">
      	<label for="internet">{tmpl_var name='internet_txt'}</label>
        <input name="internet" id="internet" value="{tmpl_var name='internet'}" size="30" maxlength="255" type="text" class="textInput" />
			</div>
      <div class="ctrlHolder">
      	<label for="icq">{tmpl_var name='icq_txt'}</label>
        <input name="icq" id="icq" value="{tmpl_var name='icq'}" size="30" maxlength="255" type="text" class="textInput" />
			</div>
	  <div class="ctrlHolder">
      	<label for="vat_id">{tmpl_var name='vat_id_txt'}</label>
        <input name="vat_id" id="vat_id" value="{tmpl_var name='vat_id'}" size="30" maxlength="255" type="text" class="textInput" />
	  </div>
	  <div class="ctrlHolder">
      	<label for="company_id">{tmpl_var name='company_id_txt'}</label>
        <input name="company_id" id="company_id" value="{tmpl_var name='company_id'}" size="30" maxlength="255" type="text" class="textInput" />
	  </div>
	  <div class="ctrlHolder">
      	<label for="bank_account_owner">{tmpl_var name='bank_account_owner_txt'}</label>
        <input name="bank_account_owner" id="bank_account_owner" value="{tmpl_var name='bank_account_owner'}" size="30" maxlength="255" type="text" class="textInput" />
			</div>
	  <div class="ctrlHolder">
      	<label for="bank_account_number">{tmpl_var name='bank_account_number_txt'}</label>
        <input name="bank_account_number" id="bank_account_number" value="{tmpl_var name='bank_account_number'}" size="30" maxlength="255" type="text" class="textInput" />
			</div>
      <div class="ctrlHolder">
      	<label for="bank_code">{tmpl_var name='bank_code_txt'}</label>
        <input name="bank_code" id="bank_code" value="{tmpl_var name='bank_code'}" size="30" maxlength="255" type="text" class="textInput" />
			</div>
      <div class="ctrlHolder">
      	<label for="bank_name">{tmpl_var name='bank_name_txt'}</label>
        <input name="bank_name" id="bank_name" value="{tmpl_var name='bank_name'}" size="30" maxlength="255" type="text" class="textInput" />
			</div>
      <div class="ctrlHolder">
      	<label for="bank_account_iban">{tmpl_var name='bank_account_iban_txt'}</label>
        <input name="bank_account_iban" id="bank_account_iban" value="{tmpl_var name='bank_account_iban'}" size="30" maxlength="255" type="text" class="textInput" />
			</div>
      <div class="ctrlHolder">
      	<label for="bank_account_swift">{tmpl_var name='bank_account_swift_txt'}</label>
        <input name="bank_account_swift" id="bank_account_swift" value="{tmpl_var name='bank_account_swift'}" size="30" maxlength="255" type="text" class="textInput" />
			</div>
	  {tmpl_var name='required_fields_txt'}
	  <div class="buttonHolder buttons">
      <button class="positive iconstxt icoPositive" type="button" value="{tmpl_var name='btn_save_txt'}" onClick="submitForm('pageForm','billing/dashboard_client_edit.php');"><span>{tmpl_var name='btn_save_txt'}</span></button>
      <button class="negative iconstxt icoNegative" type="button" value="{tmpl_var name='btn_cancel_txt'}" onClick="loadContent('dashboard/dashboard.php');"><span>{tmpl_var name='btn_cancel_txt'}</span></button>
    </div>
    </fieldset>

    <input type="hidden" name="id" value="{tmpl_var name='id'}">

    
  </div>
  
</div>
