<?php
$atts = array(
              'width'      => '600',
              'height'     => '600',
              'scrollbars' => 'yes',
              'status'     => 'no',
              'resizable'  => 'no',
              'screenx'    => '20',
              'screeny'    => '50',
    'class'=>'btn btn-primary'
            );
?>
<div class="col-sm-9 col-sm-offset-3 col-md-10 col-md-offset-2 main">
    <div class="panel panel-primary">
        <div class="panel panel-heading">Confirm Details</div>
        <div class="panel-body">
                        <?php 
                        $form=array('target'=>'_new');
                        echo form_open_multipart('welcome/insertDetails'); ?>
                        <div class="row">
                            <div class="col-sm-6" style="margin-bottom:10px !important;">
                                <div class="input-group">
                                    <span class="input-group-addon">Select Category</span>
                                    <select class="form-control" required="required" name="category" readonly>
                                        <option value="">Select Category</option>
                                        <?php
                                        foreach($categories as $c){ ?>
                                        <option value="<?php echo $c['confcatID']; ?>" <?php if($category==$c['confcatID']){echo "selected"; } ?>><?php echo $c['confcatName']; ?></option>
                                        <?php } ?>
                                    </select>
                                </div>
                            </div>
                            <div class="col-sm-6" style="margin-bottom:10px !important;">
                                <div class="input-group">
                                    <span class="input-group-addon">NIQS Membership Number</span>
                                    <input type="text" class="form-control" name="niqsNo" id="niqsNo" value="<?php echo $niqsNo; ?>" readonly  />
                                </div>
                            </div>
                        </div>
                        <div class="row" style="margin-bottom:10px !important;">
                        <div class="col-sm-12">
                            <div class="input-group">
                                <span class="input-group-addon">Amount</span>
                                <input type="text" class="form-control" name="amount"  id='amount' value="<?php echo $amount; ?>" readonly  />
                            </div>
                        </div>
                    </div>
                        <div class="row" style="margin-bottom:10px !important;">
                            <div class="col-sm-12">
                                <div class="input-group">
                                    <span class="input-group-addon">Full Name</span>
                                    <input type="text" class="form-control" required="required" name="names" readonly value="<?php echo $names; ?>" />
                                </div>
                            </div>
                        </div>
                        <div class="row" style="margin-bottom:10px !important;">
                            <div class="col-sm-6" style="margin-bottom:10px !important;">
                                <div class="input-group">
                                    <span class="input-group-addon">Grade</span>
                                    <select class="form-control" required="required" name="grade" readonly>
                                        <option value="">Select Grade</option>
                                        <?php
                                        foreach($grade2 as $g){ ?>
                                        <option value="<?php echo $g['gradeID']; ?>" <?php if($grade==$g['gradeID']){echo "selected"; } ?>><?php echo $g['gradeName']; ?></option>
                                        <?php }  ?>
                                    </select>
                                    
                                </div>
                            </div>
                            <div class="col-sm-6">
                                <div class="input-group">
                                    <span class="input-group-addon">Chapter</span>
                                    <select class="form-control" required="required" name="chapter" readonly>
                                        <option value="">Select Chapter</option>
                                        <?php
                                        foreach($state2 as $s){ ?>
                                        <option value="<?php echo $s['stateid']; ?>" <?php if($chapter==$s['stateid']){echo "selected"; } ?>><?php echo $s['state_name']; ?></option>
                                        <?php } ?>
                                    </select>
                                </div>
                            </div>
                        </div>
                        <div class="row" style="margin-bottom:10px !important;">
                            
                        </div>
                        <div class="row" style="margin-bottom:10px !important;">
                            <div class="col-sm-4" style="margin-bottom:10px !important;">
                                <div class="input-group">
                                    <span class="input-group-addon">Phone</span>
                                    <input type="number" name="phone" required="required" class="form-control" readonly value="<?php echo $phone; ?>" />
                                </div>
                            </div>
                            <div class="col-sm-8">
                                <div class="input-group">
                                    <span class="input-group-addon">Email Address</span>
                                    <input type="email" class="form-control" name="email" required="required" readonly value="<?php echo $email; ?>" />
                                </div>
                            </div>
                        </div>
                        <div class="row" style="margin-bottom:10px !important;">
                            
                        </div>
                        <div class="row" style="margin-bottom:10px !important;">
                            <div class="col-sm-12">
                                <div class="input-group">
                                    <span class="input-group-addon">Company</span>
                                    <input type="text" class="form-control" name="company" required="required" readonly value="<?php echo $company; ?>" />
                                </div>
                            </div>
                        </div>
                        <div class="row" style="margin-bottom:10px !important;">
                            <div class="col-sm-12">
                                <div class="input-group">
                                    <span class="input-group-addon">Address</span>
                                    <textarea class="form-control" name="address" required="required" rows="5" readonly><?php echo $address; ?></textarea>
                                </div>
                            </div>
                        </div>
                        <div class="row" style="margin-bottom:10px !important;">
                            <div class="col-sm-6" style="margin-bottom:10px !important;">
                                <div class="input-group">
                                    <span class="input-group-addon">Postal Code</span>
                                    <input type="number" class="form-control" name="postal" required="required" readonly value="<?php echo $postal; ?>" />
                                </div>
                            </div>
                            <div class="col-sm-6">
                                <div class="input-group">
                                    <span class="input-group-addon">Country</span>
                                    <select class="form-control" required="required" name="country" readonly>
                                        <option value="">Select Country</option>
                                        <?php
                                        foreach($country2 as $co){ ?>
                                        <option value="<?php echo $co['id']; ?>"<?php if($country==$co['id']){echo "selected";} ?>><?php echo $co['value']; ?></option>
                                        <?php } ?>
                                    </select>
                                </div>
                            </div>
                        </div>
                     <div class="row" style="margin-bottom:10px !important;">
                            <div class="col-sm-6" style="margin-bottom:10px !important;">
                                <div class="input-group">
                                    <span class="input-group-addon">Teller No</span>
                                    <input type="text" class="form-control" name="tellerNo" required="required"/>
                                </div>
                            </div>
                            <div class="col-sm-6">
                                <div class="input-group">
                                    <span class="input-group-addon">Payment Date</span>
                                    <input type="date" name="payDate" required class="form-control" /> 
                                </div>
                            </div>
                        </div>
                        <div class="row" style="margin-bottom:10px !important;">
                            <div class="col-sm-6">
                                <div class="input-group">
                                    <span class="input-group-addon">Payment Mode</span>
                                    <select name="paymode" required class="form-control" > 
										<option value="firstbank">Cheque</option>
										<option value="gtbank">POS</option>
										<option value="skye">Teller</option>
										<option value="uba">Transfer</option>
									</select>
                                </div>
                            </div>
							<div class="col-sm-6">
                                <div class="input-group">
                                    <span class="input-group-addon">Bank</span>
                                    <select name="bank" required class="form-control" > 
										<option value="firstbank">First Bank</option>
										<option value="gtbank">GTBank</option>
										<option value="skye">Skye Bank</option>
										<option value="uba">UBA</option>
										<option value="zenith">Zenith Bank</option>
									</select>
                                </div>
                            </div>
                        </div>
                        <div class="row" style="margin-bottom:10px !important;">
							<div class="col-sm-6">
                                <div class="input-group">
                                    <span class="input-group-addon">Cheque No.</span>
                                    <input type="text" name="form_no" class="form-control" /> 
                                </div>
                            </div>
                            <div class="col-sm-4">
                                <input type="submit" class="btn btn-danger" value="Back" onclick="window.history.back();" />   <input type="submit" class="btn btn-primary" value="Complete Registration" />
                            </div>
                        </div>
                        <?php echo form_close(); ?>
                    </div>
    </div>
    
</div>
