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<div id="submit-header" data-role="header">
<a data-rel="back" data-icon="arrow-l" class="ui-btn-left">[% loc('Back') %]</a>
<h1>[% loc('Your details') %]</h1>
</div>
<div data-role="content">
<div id="errors"></div>
<form id="passwordForm" name="passwordForm">
<div id="password_row">
<div class="inputcard">
<div>
<input data-role="none" type="password" value="" name="password" id="form_password" placeholder="[% loc('Your password') %]" required>
</div>
</div>
<div class="noborder">
<input data-role="button" data-theme="a" type="submit" id="report" name="report" value="[% loc('Report') %]">
</div>
</div>
<div id="check_name" class="nodisplay">
<div class="inputcard">
<p>
[% loc('Please confirm your name, if you want it to be public and optionally your phone number.') %]
</p>
<% if ( typeof model.titles_list !== 'undefined' ) { %>
<div>
<select data-role="none" placeholder="[% loc('Title') %]" id="form_title" name="title" required>
<option value="">[% loc('Title') %]</option>
<% for ( var i = 0; i < model.titles_list.length; i++ ) { var title = model.titles_list[i]; print( '<option value="' + title + '"' + ( user.title && user.title == title ? ' selected' : '' ) + '>' + title + '</option>' ); } %>
</select>
</div>
<% } %>
<div>
<input data-role="none" type="text" value="" id="form_name" name="name">
</div>
<div>
<input data-role="none"type="tel" value="<%= user.phone %>" name="name" id="form_phone" placeholder="[% loc('Please enter your phone number (optional)') %]">
</div>
<div data-role="fieldcontain">
<fieldset data-role="controlgroup">
<input type="checkbox" name="may_show_name" id="form_may_show_name" value="1" checked>
<label for="form_may_show_name">[% loc('Show my name publicly') %]</label>
</fieldset>
</div>
</div>
<div class="bottom-btn">
<input data-role="button" data-theme="a" type="submit" id="confirm_name" name="report" value="[% loc('Confirm name') %]">
</div>
</div>
</form>
</div>
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