<div class="row escrow-transfer">
	<div class="large-12 columns escrow-form">
		<form role="form" id="bp-form" class="custom main">
			<fieldset>
				<div id="bp-error" class="error" style="display: none;">
				  <small class="error"></small>
				</div>

				<input type="hidden" name="order_id" id="bp-order-id" value="<?php echo esc_attr( $order->get_id() ); ?>" />

				<div class="form-field"><label>
				  <?php _e( 'Name on Card', 'appthemes-balanaced-payments' ); ?><br/>
				  <input type="text" name="name" id="bp-name" autocomplete="off" placeholder="John Doe"/>
				</label></div>

				<div class="form-field"><label>
				  <?php _e( 'Card Number', 'appthemes-balanaced-payments' ); ?><br/>
				  <input type="text" name="number" id="bp-number" autocomplete="off" placeholder="4111111111111111" maxlength="16"/>
				</label></div>

				<div class="form-field"><label>
					<div class="multi-line-field">
				  		<?php _e( 'Expiration Date', 'appthemes-balanaced-payments' ); ?> <br/>
					  	<input type="text" name="month" id="bp-ex-month" autocomplete="off" placeholder="01" maxlength="2" />
					  	/
					  	<input type="text" name="year" id="bp-ex-year" autocomplete="off" placeholder="2013" maxlength="4" />
				  	</div>
				  	<div class="multi-line-field">
				  		<?php _e( 'CVV', 'appthemes-balanaced-payments' ); ?> <br/>
				  		<input type="text" name="cvv" id="bp-cvv" autocomplete="off" placeholder="453" maxlength="4" />
				  	</div>
				</label></div>

				<div class="form-field"><label>
				  <?php _e( 'Billing Address Postal Code', 'appthemes-balanaced-payments' ); ?><br/>
				  <input type="text" name="zip" id="bp-postal-code" autocomplete="off" placeholder="45312" />
				</label></div>

				<div class="form-field">
				  <button class="button success" type="submit">
					<?php _e( 'Submit', 'appthemes-balanaced-payments' ); ?>
				  </button>
				</div>
			</fieldset>
		</form>
	</div>
</div>