{txt key=TEXT_RESCISSION_FORM}

{$message} {if $show_form eq 'true'}

{txt key=TEXT_RESCISSION_FORM_INTRO}

{/if} {include file="xtCore/pages/content.html"} {if $show_form eq 'true'} {form class="form-horizontal" type=form name=login action='dynamic' link_params=getParams method=post conn=SSL} {form type=hidden name=action value=send}
{form class="form-control" id=product_numbers type=textarea name=product_numbers params='cols="50" rows="4"' value=$product_numbers}
{form id=order_date type=text name=order_date params='maxlength="40"' value=$order_date} {literal} {/literal}
{form id=recieved_date type=text name=recieved_date params='maxlength="40"' value=$recieved_date} {literal} {/literal}
{txt key=TEXT_HEADING_CUSTOMER_NAME}
{form id=firstname type=text name=firstname params='maxlength="40"' value=$firstname}
{form id=lastname type=text name=lastname params='maxlength="40"' value=$lastname}
{txt key=TEXT_HEADING_CUSTOMER_ADDRESS}
{form id=street type=text name=street params='maxlength="40"' value=$street}
{form id=city type=text name=city params='maxlength="40"' value=$city}
{form params='id="country" style="float:right""' type=select name=country value=$country_data default=$smarty.const._STORE_COUNTRY}
{form id=email_address type=text name=email_address params='maxlength="40"' value=$email_address}
{form id=client_number type=text name=client_number params='maxlength="40"' value=$client_number}
{form id=invoice_number type=text name=invoice_number params='maxlength="40"' value=$invoice_number}
{form class="form-control" id=customer_message type=textarea name=customer_message params='cols="50" rows="4"' value=$customer_message}
{form id=revocation_date type=text name=revocation_date params='maxlength="40"' value=$revocation_date} {literal} {/literal}
{if $smarty.const._STORE_CAPTCHA == 'ReCaptcha'}
{else if $smarty.const._STORE_CAPTCHA == 'Standard'}

{txt key=TEXT_CAPTCHA}

{form id=captcha_code type=text name=captcha params='maxlength="30"'}
{/if}

{txt key=TEXT_MUST}

{form type=formend} {/if}