<div class="ecp-component ecp_CancelClubSubscription">
  <form class="ecp-form">
    <input type="hidden" name="subscription_id" value="{message:subscription_id}">
    <h2>{message:CancelClubSubscription/Title}</h2>

    <div class="ecp-section ecp-bottomline">
      <div class="ecp-sized-left-col">
        <p>{message:CancelClubSubscription/TierNameLabel}</p>
        <p>{message:club_tier_name}</p>
      </div>
      <div class="ecp-sized-left-col" data-ecp-handle="pickup_info">
        <p>{message:CancelClubSubscription/PickupLabel}</p>
        <dl class="ecp-address">
          <dt>{message:shipping_first_name} {message:shipping_last_name}</dt>
          <dd data-ecp-handle="shipping_phone">{message:CancelClubSubscription/PhoneLabel} {message:shipping_phone}</dd>
        </dl>
      </div>
      <div class="ecp-sized-left-col" data-ecp-handle="shipping_info">
        <p>{message:CancelClubSubscription/ShippingLabel}</p>
        <dl class="ecp-address">
          <dt>{message:shipping_first_name} {message:shipping_last_name}</dt>
          <dd data-ecp-handle="shipping_company_name">{message:shipping_company_name}</dd>
          <dd>{message:shipping_address_line_1}</dd>
          <dd data-ecp-handle="shipping_address_line_2">{message:shipping_address_line_2}</dd>
          <dd>{message:shipping_city}, <span data-ecp-handle="shipping_state_code">{message:shipping_state_code}</span><span data-ecp-handle="shipping_region">{message:shipping_region}</span> {message:shipping_postal_code}<span  data-ecp-handle="shipping_zip_extension">-{message:shipping_zip_extension}</span></dd>
          <dd>{message:shipping_country_name}</dd>
          <dd data-ecp-handle="shipping_phone">{message:CancelClubSubscription/PhoneLabel} {message:shipping_phone}</dd>
        </dl>
      </div>
    </div>    
    
    <div class="ecp-section">
      <p>{message:CancelClubSubscription/Overview}</p>
    </div>

    <div class="ecp-section">
      <div>
        <label class="ecp-form-input-label">{message:CancelClubSubscription/CancelReasonLabel}</label>
        <select name="cancel_reason_id"></select>
      </div>
    </div>
    
    <div class="ecp-section">
      <div>
        <label class="ecp-form-input-label">{message:CancelClubSubscription/NoteLabel}</label>
        <textarea name="status_change_note" rows="3" placeholder="{message:CancelClubSubscription/NotePlaceholder}"></textarea>
      </div>
    </div>
    
    <div class="ecp-form-buttonset-2 ecp-clearfix">
      <button data-ecp-action="save">{message:CancelClubSubscription/ProceedButton}</button>
      <button class="ecp-secondary" data-ecp-action="cancel">{message:CancelClubSubscription/ExitButton}</button>
    </div>
  </form>
</div>