{@ include(common/header) @}
      <h2>新規顧客様作成</h2>
      <p>
        <form method="POST" action="/openprovider/createcustomer">
          <h3>会社情報</h3>
          <p>個人の場合、入力が不要です。</p>
          <table>
            <tbody>
              <tr>
                <td><label for="company_name">会社名</label></td>
                <td><input type="text" name="company_name" value="{{ $data['company_name'] }}" /></td>
              </tr>
              <tr>
                <td><label for="company_registration_number">法人番号</label></td>
                <td><input type="text" name="company_registration_number" value="{{ $data['company_registration_number'] }}" /></td>
              </tr>
              <tr>
                <td><label for="company_url">ウェブサイト</label></td>
                <td><input type="text" name="company_url" value="{{ $data['company_url'] }}" /></td>
              </tr>
            </tbody>
          </table>
          <h3>個人情報</h3>
      telephone number (req)
      fax number
      email address (req)
      birth date
          <table>
            <tbody>
              <tr>
                <td><label for="last_name">姓名（ローマ字）*</label></td>
                <td>
                  <input type="text" name="last_name" placeholder="Taro" value="{{ $data['last_name'] }}" />
                  <input type="text" name="first_name" placeholder="Yamada" value="{{ $data['first_name'] }}" />
                </td>
              </tr>
              <tr>
                <td><label for="phone.country_code">電話番号*</label></td>
                <td>
                  <input type="text" name="phone.country_code" placeholder="+81" value="{{ $data['phone.country_code'] }}" />
                  <input type="text" name="phone.area_code" placeholder="43" value="{{ $data['phone.area_code'] }}" />
                  <input type="text" name="phone.subscriber_number" placeholder="0000000" value="{{ $data['phone.subscriber_number'] }}" />
                </td>
              </tr>
              <tr>
                <td><label for="fax.country_code">FAX</label></td>
                <td>
                  <input type="text" name="fax.country_code" placeholder="+81" value="{{ $data['fax.country_code'] }}" />
                  <input type="text" name="fax.area_code" placeholder="43" value="{{ $data['fax.area_code'] }}" />
                  <input type="text" name="fax.subscriber_number" placeholder="0000000" value="{{ $data['fax.subscriber_number'] }}" />
                </td>
              </tr>
              <tr>
                <td><label for="email">メールアドレス*</label></td>
                <td><input type="text" name="email" placeholder="taro@076.co.jp" value="{{ $data['email'] }}" /></td>
              </tr>
              <tr>
                <td><label for="year">生年月日</label></td>
                <td>
                  <input type="text" name="year" placeholder="1970" value="{{ $data['year'] }}" />年
                  <input type="text" name="month" placeholder="12" value="{{ $data['month'] }}" />月
                  <input type="text" name="day" placeholder="31" value="{{ $data['day'] }}" />日
                </td>
              </tr>
            </tbody>
          </table>
          <h3>住所情報</h3>
          <table>
            <tbody>
              <tr>
                <td><label for="zipcode">郵便番号*（ハイフン付き）</label></td>
                <td>〒<input type="text" name="zipcode" value="{{ $data['zipcode'] }}" /></td>
              </tr>
              <tr>
                <td><label for="state">都道府県*</label></td>
                <td><input type="text" name="state" value="{{ $data['state'] }}" /></td>
              </tr>
              <tr>
                <td><label for="city">市区町村*</label></td>
                <td><input type="text" name="city" value="{{ $data['city'] }}" /></td>
              </tr>
              <tr>
                <td><label for="street">町名*</label></td>
                <td><input type="text" name="street" value="{{ $data['street'] }}" /></td>
              </tr>
              <tr>
                <td><label for="number">番地*</label></td>
                <td><input type="text" name="number" value="{{ $data['number'] }}" /></td>
              </tr>
              <tr>
                <td><label for="country">国</label></td>
                <td>
                  <select name="country">
                    <option value="JP" selected="selected">日本</option>
                    <option value="NL">オランダ</option>
                  </select>
                </td>
              </tr>
              <tr>
                <td><label for="comments">メモ</label></td>
                <td><input type="text" name="comments" value="{{ $data['comments'] }}" /></td>
              </tr>
            </tbody>
          </table>
          <button>送信</button>
        </form>
      </p>
      {@ kys($data) @}
{@ include(common/footer) @}