87 lines
4.5 KiB
PHP
87 lines
4.5 KiB
PHP
<!-- Main content -->
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<div class="content-wrapper">
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<?php include('common/userstrip.php'); ?>
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<!-- Marketing campaigns -->
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<div class="panel panel-flat">
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<div class="panel-heading">
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<form class="form-horizontal" action="/member/addreccipient" method='POST'>
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<div class="row">
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<div class="col-md-10 col-md-offset-1">
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<h5 class="panel-title">Add Bank Account</h5>
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</div>
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</div>
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<div class="panel-body">
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<div class="row">
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</div>
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<div class="col-md-10 col-md-offset-1">
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<div class="form-group">
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<label class="col-lg-3 control-label"> First Name:</label>
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<div class="col-lg-9">
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<input name ="firstname" type="text" class="form-control" placeholder="Account firstname" value="<?php echo $firstname; ?>" >
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</div>
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</div>
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<div class="form-group">
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<label class="col-lg-3 control-label"> Last Name:</label>
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<div class="col-lg-9">
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<input name ="lastname" type="text" class="form-control" placeholder="Account lastname" value="<?php echo $lastname; ?>" >
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</div>
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</div>
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<div class="form-group">
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<label class="col-lg-3 control-label">Country:</label>
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<div class="col-lg-9">
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<?php echo $country_combo; ?>
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</div>
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</div>
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<div class="form-group">
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<label class="col-lg-3 control-label">Bank Name:</label>
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<div class="col-lg-9">
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<?php echo $bank_combo; ?>
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</div>
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</div>
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<div class="form-group">
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<label class="col-lg-3 control-label"> Account Number :</label>
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<div class="col-lg-9">
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<input name="account_no" type="text" class="form-control" placeholder="Account No" value="<?php echo $account_no; ?>" onKeyUp="this.value = this.value.replace(/[^0-9]/g, '');" >
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</div>
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</div>
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<div class="form-group">
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<label class="col-lg-3 control-label"> Repeat Account No :</label>
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<div class="col-lg-9">
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<input name="account_no_repeat" type="text" class="form-control" placeholder="Repeat Account No" value="<?php echo $account_no_repeat; ?>" onKeyUp="this.value = this.value.replace(/[^0-9]/g, '');" >
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</div>
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</div>
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<div class="form-group">
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<label class="col-lg-3 control-label"> Account Type :</label>
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<div class="col-lg-9">
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<?php echo $account_type_combo; ?>
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</div>
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</div>
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<div class="form-group">
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<label class="col-lg-3 control-label">State/Province:</label>
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<div class="col-lg-9">
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<input type="text" class="form-control" placeholder="State/Province" name="state" value='<?php echo $state; ?>'>
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</div>
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</div>
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<div class="form-group">
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<label class="col-lg-3 control-label">City:</label>
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<div class="col-lg-9">
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<input type="text" class="form-control" placeholder="City" name="city" value='<?php echo $city; ?>'>
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</div>
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</div>
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<?php echo $add_error; ?>
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<div class="text-right">
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<button type="submit" class="btn btn-primary">Add Recipient <i class="icon-arrow-right14 position-right"></i></button>
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</div>
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</div>
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</div>
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</form>
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</div>
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</div>
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<!-- /marketing campaigns -->
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</div>
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<!-- /main content -->
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