Hacked By AnonymousFox

<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">&times;</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>