50 lines
2.3 KiB
PHP
Executable File
50 lines
2.3 KiB
PHP
Executable File
<?php
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// $this->titre = "ISA WEB - Nouveau Dossier Remboursement classique";
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$idPolice = $_SESSION['idPolice_C'] ;
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?>
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<legend> <?= _("Nouveau Dossier Hors Tiers Payant") . " / " . $_SESSION['nomClient_C'] . " => " . _("ID Police") . " : " .$idPolice ?> </legend>
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<table class="table table-responsive table-condensed" style='font-size:10pt;'>
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<tbody>
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<tr>
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<td width="10%" class="required"> <?= _("Date réclamation") ?> </td>
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<td width="20%"> <INPUT class="form-control datepicker" TYPE="text" id="dateReclamation" NAME="dateReclamation" value="" required style='font-size:10pt;' AUTOCOMPLETE="OFF"></td>
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<td width="10%" align="center"> Observations </td>
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<td> <INPUT class="form-control" TYPE="text" id="observations" NAME="observations" style='font-size:10pt;' AUTOCOMPLETE="OFF"></td>
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</tr>
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<tr>
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<td colspan="4"> <input style='text-align:center; font-size:11pt; background-color:green;color:white;' class="form-control" type="text" value= "Informations sur le paiement proposées par le bénéficiaire" disabled > </td>
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</tr>
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<tr>
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<td class="required"> <?= _("Mode Paiement") ?> </td>
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<td>
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<SELECT class="form-control" id="codeModePaiementDemande" NAME="codeModePaiementDemande" required style='font-size:10pt;' AUTOCOMPLETE="OFF">
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<?php liste_options($modepaiement,$_SESSION['codeModePaiement_C']); ?>
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</SELECT>
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</td>
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<td align="center" class="required"> <?= _("Banque") ?> </td>
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<td>
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<SELECT style='font-size:10pt;' class="form-control" id="codeBanqueBeneficiaire" NAME="codeBanqueBeneficiaire" required AUTOCOMPLETE="OFF">
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<?php liste_options($banque, ""); ?>
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</SELECT>
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</td>
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</tr>
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<tr>
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<td class="required"> <?= _("No Compte Bancaire") ?> </td>
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<td > <INPUT style='font-size:10pt;' class="form-control" TYPE="text" id="numeroCompteBeneficiaire" NAME="numeroCompteBeneficiaire" value="<?= $_SESSION['rib_C'] ?>" required AUTOCOMPLETE="OFF"> </td>
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<td> </td>
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<td> <input id="btn_enreg" name="btn_enreg" class = "form-control btn btn-primary" type="button" value="<?= _("Enregistrer le Dossier...") ?>" onClick="javascript:enregistrer_dossier_classique_police();" style='font-size:10pt;' > </td>
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</tr>
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</tbody>
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</table>
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