<div class="modal fade" id="exampleModal" tabindex="-1" role="dialog" aria-labelledby="exampleModalLabel" aria-hidden="true">
<div class="modal-dialog" role="document">
<div class="modal-content">
<div class="modal-header">
<h5 class="modal-title">Verify Order #</h5>
<button type="button" class="close" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span>
</button>
</div>
<form method="post" id="verifyOrder">
<div class="modal-body">
<div class="alert alert-success" role="alert" style="display:none"></div>
<div class="row">
<div class="col-md-6">
<div class="form-group">
<label for="exampleInputCity1">Order Receive Amount <span styl="color:red">*</span></label>
<input type="hidden" name="orderId" id="orderId"/>
<input type="hidden" name="receiptId" id="receiptid"/>
<input type="hidden" name="distributorid" id="distributorid"/>
<input type="text" class="form-control" name="receive_amount" value="" placeholder="Receive Amount" required="">
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label for="exampleInputCity1">Payment Receive Date <span styl="color:red">*</span></label>
<input type="text" class="form-control datepicker" name="receive_date" placeholder="Receive Date" value="<?php echo date('d-m-Y');?>" required="">
</div>
</div>
<div class="col-md-12">
<div class="form-group">
<label for="exampleInputCity1">Order Remark</label>
<textarea class="form-control" name="orderRemark" placeholder="Order Remark" name="remark"></textarea>
</div>
</div>
</div>
</div>
<div class="modal-footer">
<button type="button" class="btn btn-secondary" data-dismiss="modal">Close</button>
<button type="submit" class="btn btn-primary">Save changes</button>
</div>
</form>
</div>
</div>
</div>