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<form action="{{ action }}" method="get"><input type="hidden" name="mid" value="{{ mid }}" /><input type="hidden" name="amt" value="{{ amt }}" /><input type="hidden" name="amt_editable" value="N" /><input type="hidden" name="currency" value="{{ currency }}" /><input type="hidden" name="ref" value="{{ ref }}" /><input type="hidden" name="pmt_sender_email" value="{{ pmt_sender_email }}" /><input type="hidden" name="pmt_contact_firstname" value="{{ pmt_contact_firstname }}" /><input type="hidden" name="pmt_contact_surname" value="{{ pmt_contact_surname }}" /><input type="hidden" name="pmt_contact_phone" value="{{ pmt_contact_phone }}" /><input type="hidden" name="pmt_country" value="{{ pmt_country }}" /><input type="hidden" name="regindi_address1" value="{{ regindi_address1 }}" /><input type="hidden" name="regindi_address2" value="{{ regindi_address2 }}" /><input type="hidden" name="regindi_sub" value="{{ regindi_sub }}" /><input type="hidden" name="regindi_state" value="{{ regindi_state }}" /><input type="hidden" name="regindi_pcode" value="{{ regindi_pcode }}" /><input type="hidden" name="return" value="{{ return }}" /><input type="hidden" name="popup" value="false" /><div class="buttons"><div class="pull-right"><input type="submit" value="{{ button_confirm }}" class="btn btn-primary" /></div></div></form>