<div class="content-header">
  <h4>{{i18n 'Read and Sign'}}</h4>
  <p class="sub-text">{{i18n 'Please carefully read and complete the form below'}}</p>
</div>
<div class="item">
  <div class="legal-text">
    <p>{{i18n 'I certify under penalty of perjury that I have a good faith belief that this portion of my VoD should be unmuted because of the following:'}}</p>
    <table class="music-table checklist">
      <thead>
        <tr>
          <th class="track-name"><span class="sub-text">{{i18n 'Track'}}</span></th>
          <th class="appeal-reason"><span class="sub-text">{{i18n 'Appeal Reason'}}</span></th>
        </tr>
      </thead>
      <tbody>
        {{#each mutedTracks as |track|}}
          {{video/appeals/muted-track track=track selectedTracks=true}}
        {{/each}}
      </tbody>
    </table>
    <p>{{i18n 'I consent to the jurisdiction of the United States Federal District Court for the Northern District of California for any disputes related to this matter.'}}</p>
  </div>
</div>
<form class="legal-form">
  <div class="item">
    <div class="form-column">
      <label>{{i18n 'Legal Full Name'}}</label>
      {{input type="text" class="text" value=fullName}}
    </div>
  </div>

  <div class="item">
    <div class="form-column">
      <label>{{i18n 'Street Address 1'}}</label>
      {{input type="text" class="text" value=streetPrimary}}
    </div>
    <div class="form-column">
      <label>{{i18n 'Street Address 2'}}</label>
      {{input type="text" class="text" value=streetSecondary placeholder="optional"}}
    </div>
  </div>
  <div class="item">
    <div class="form-column">
      <label>{{i18n 'City'}}</label>
      {{input type="text" class="text" value=city}}
    </div>
    <div class="form-column">
      <label>{{i18n 'State / Province'}}</label>
      {{input type="text" class="text" value=province}}
    </div>
  </div>
  <div class="item">
    <div class="form-column">
      <label>{{i18n 'Zip / Postal Code'}}</label>
      {{input type="text" class="text" value=zipcode}}
    </div>
    <div class="form-column">
      <label>{{i18n 'Country'}}</label>
      {{input type="text" class="text" value=country}}
    </div>
  </div>
</form>
<div class="buttons">
  <div {{action 'selectMoreTracks'}} class="button button--text"><span>{{t 'general.forms.back'}}</span></div>
  <div {{action 'submitAppeal'}} class="button {{if submittingAppeal 'disabled'}}"><span>{{t 'general.forms.submit'}}</span></div>
</div>
