<div class="mbp-select-level">
	<form id="mbp-select-level" method="post" action="__submit_url__" onsubmit="javascript:return __js_object__.onSubmit(this)">
		<div class="mbp-available-levels-wrp">
			<div class="mbp-available-levels">
				<bx_repeat:levels>__level__</bx_repeat:levels>
			</div>
		</div>
		<bx_if:show_providers_selector>
			<div class="mbp-select-provider bx-def-margin-top"<bx_if:show_providers_selector_hidden> style="display:none;"</bx_if:show_providers_selector_hidden>>
				<div class="mbp-sp-caption bx-def-margin-sec-bottom bx-def-font-grayed">
					<bx_text:_membership_txt_select_payment />
				</div>
				<bx_repeat:providers>
					<div class="pmt-provider">
	                	<input type="radio" name="provider" value="__name__" __checked__ />
	                    <b>__caption__</b>
					</div>
				</bx_repeat:providers>
			</div>
		</bx_if:show_providers_selector>
		<bx_if:show_captcha>
			<div class="mbp-captcha bx-def-margin-top">
				__captcha__
				<input type="hidden" name="captcha" value="" />
			</div>
		</bx_if:show_captcha>
		<div class="mbp-pay bx-def-margin-top">
			<bx_if:show_selected_provider>
				<input type="hidden" name="provider" value="__name__" />
			</bx_if:show_selected_provider>
			<input class="bx-btn mbp-checkout" type="submit" name="mbp-checkout" value="__txt_checkout__" />
			<div class="mbp-cb">&nbsp;</div>
		</div>
	</form>
	__js_code__
</div>