101 lines
4.1 KiB
PHP
101 lines
4.1 KiB
PHP
<?php
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$this->titre = "INTER-SANTE - Demande Frais Funéraires";
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?>
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<form id="frmderogation" name="frmderogation" method="post" >
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<legend> <?= _("Fiche de demande de Frais Funéraires") ?> </legend>
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<input class="sr-only" type="text" id="fraisReel" name="fraisReel" value="<?= $montant_fraisfuneraire ?>">
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<table class="table table-responsive table-condensed" style='font-size:10pt;'>
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<tbody>
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<tr>
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<td width="10%" > <?= _("Demandeur") ?> </td>
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<td width="50%" ><INPUT class="form-control" TYPE="text" id="demandeur" NAME="demandeur" style='font-size:10pt;' required AUTOCOMPLETE="OFF" autofocus></td>
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<td width="10%" align="center"> <?= _("Lien Parenté") ?> </td>
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<td>
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<SELECT class="form-control" id="codeLienDemandeur" NAME="codeLienDemandeur" required AUTOCOMPLETE="OFF" style='font-size:10pt;'>
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<?php liste_options($liendemandeur,""); ?>
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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> <?= _("Cause décès") ?> </td>
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<td ><INPUT class="form-control" TYPE="text" id="causeDeces" NAME="causeDeces" style='font-size:10pt;' required AUTOCOMPLETE="OFF" ></td>
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<td align="center"> <?= _("Décédé le") ?> </td>
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<td><INPUT class="form-control datepicker" TYPE="text" id="dateDeces" NAME="dateDeces" Value="" style='font-size:10pt;' required AUTOCOMPLETE="OFF" ></td>
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</tr>
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<tr>
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<td> <?= _("Bénéficiaire") ?> </td>
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<td ><INPUT class="form-control" TYPE="text" id="beneficiaireReglement" NAME="beneficiaireReglement" style='font-size:10pt;' required AUTOCOMPLETE="OFF" ></td>
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<td align="center"> <?= _("Lien Parenté") ?> </td>
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<td>
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<SELECT class="form-control" id="codeLienBeneficiaire" NAME="codeLienBeneficiaire" required AUTOCOMPLETE="OFF" style='font-size:10pt;'>
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<?php liste_options($lienbeneficiaire,""); ?>
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</SELECT>
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</td>
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</tr>
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<tr>
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<td> Observations </td>
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<td colspan="3"><INPUT class="form-control" TYPE="text" id="observations" NAME="observations" style='font-size:10pt;' ></td>
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</tr>
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<tr>
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<td> <?= _("Frais") ?> </td>
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<td> <input class="form-control" style="background-color: rgb(190,190,190);text-align: center; font-size:10pt;'" type="text" value="<?= format_N($montant_fraisfuneraire) ?>" disabled> </td>
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<td align="center" > <?= _("Retenu") ?> </td>
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<td> <INPUT class="form-control" style='font-size:10pt; text-align:center' TYPE="number" id="montantApayer" NAME="montantApayer" required AUTOCOMPLETE="OFF" value="<?= $montant_fraisfuneraire ?>" readonly > </td>
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</tr>
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<tr>
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<td colspan="4"> <input style='text-align:center; font-size:11pt; background-color:green;color:white;' class="form-control" type="text" value= "Informations sur le paiement proposées par le bénéficiaire" disabled > </td>
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</tr>
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<tr>
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<td > <?= _("Mode P") ?> </td>
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<td>
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<SELECT class="form-control" id="codeModePaiementDemande" NAME="codeModePaiementDemande" required AUTOCOMPLETE="OFF" style='font-size:10pt;' >
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<?php liste_options($modepaiement,""); ?>
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</SELECT>
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</td>
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<td align="center"> <?= _("Banque Bénéf") ?> </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($banque, ""); ?>
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</SELECT>
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</td>
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</tr>
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<tr>
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<td> <?= _("No Cpte Bénéf") ?> </td>
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<td > <INPUT style='font-size:10pt;' class="form-control" TYPE="text" id="numeroCompteBeneficiaire" NAME="numeroCompteBeneficiaire" required AUTOCOMPLETE="OFF" > </td>
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<td> </td>
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<td colspan="1"> <input id="btn_enreg" name="btn_enreg" class = "form-control btn btn-primary" type="button" value="<?= _("Enregistrer la demande") ?>" onClick="enregistrerdemandefraisfuneraire();" style='font-size:10pt;' > </td>
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</tr>
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</tbody>
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</table>
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<?php if (isset($msgErreur)): ?>
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<div id ="msgErreur" class="alert alert-danger" style="height:38px; padding:5px;" >
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<H4><?= $msgErreur ?></H4>
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</div>
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<?php endif; ?>
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</form>
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<div id="div_test">
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</div>
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