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Необходима правка шаблона + небольшая правка кода под шаблон

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Добрый день, существует шаблон и существует страничка с оплатой:




Задача состоит в том чтобы поправить эту страничку и привести к виду



Плюс хотелось бы удаление полей: Компания, компания_id, индекс, адрес_2, кажется все указал.


p.s Хотелось бы выполнить эту работа и все правки именно на текущем шаблоне. не предлагайте установку модулей и дополнений.

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