{txt key=TEXT_RESCISSION_FORM}

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

{txt key=TEXT_RESCISSION_FORM_INTRO}

{form type=form name=login action='dynamic' link_params=getParams method=post conn=SSL} {form type=hidden name=action value=send} {form id=product_numbers type=textarea name=product_numbers params='cols="50" rows="15"' value=$product_numbers} {form id=order_date type=text name=order_date params='maxlength="40"' value=$order_date} {form id=recieved_date type=text name=recieved_date params='maxlength="40"' value=$recieved_date}

{$smarty.const.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}

{$smarty.const.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=$invoice_number} {form id=customer_message type=textarea name=customer_message params='cols="50" rows="15"' value=$customer_message} {form id=revocation_date type=text name=revocation_date params='maxlength="40"' value=$revocation_date} {if $recaptcha eq 'true'} {$captcha_link} {else}

{txt key=TEXT_CAPTCHA}

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

{css_button text=$smarty.const.BUTTON_SUBMIT type='form'}

{form type=formend}

{txt key=TEXT_MUST}

{literal} {/literal} {/if}