54 lines
1.9 KiB
PHP
Executable File
54 lines
1.9 KiB
PHP
Executable File
<?php
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?>
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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 class="required" width="13%"> <?= _("Bénéficiaire") ?> </td>
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<td width="50%"><INPUT class="form-control majuscule" TYPE="text" id="beneficiaireReglement" NAME="beneficiaireReglement" style='font-size:10pt;' required AUTOCOMPLETE="OFF"></td>
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<td align="center" class="required"> <?= _("Lien Parenté") ?> </td>
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<td>
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<select class="form-select" id="codeLienBeneficiaire" NAME="codeLienBeneficiaire" required AUTOCOMPLETE="OFF" style='font-size:10pt;'>
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<?php liste_options($lienbeneficiaire,""); ?>
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</SELECT>
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</td>
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</tr>
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<tr>
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<td class="required"> <?= _("Mode Paiement") ?> </td>
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<td>
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<select class="form-select" id="codeModePaiement" NAME="codeModePaiement" required AUTOCOMPLETE="OFF" style='font-size:10pt;' >
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<?php liste_options($modepaiement,""); ?>
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</SELECT>
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</td>
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<td align="center"> <?= _("En vigueur?") ?> </td>
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<td>
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<SELECT style='font-size:10pt;' class="form-select" id="enVigueur" NAME="enVigueur" required AUTOCOMPLETE="OFF">
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<?php liste_options($ouinonenvigueur, "1",true); ?>
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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 > <?= _("Téléphone Portable") ?> </td>
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<td>
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<INPUT class="form-control" TYPE="text" id="telephoneMobile" NAME="telephoneMobile" style='font-size:10pt;' readonly>
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</td>
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<td align="center"> <?= _("RIB") ?> </td>
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<td>
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<INPUT class="form-control majuscule" TYPE="text" id="rib" NAME="rib" style='font-size:10pt;' readonly>
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</td>
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</tr>
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<tr>
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<td colspan="4"> <input id="btn_enreg" name="btn_enreg" class = "form-control btn btn-primary" type="button" value="<?= _("Ajouter") ?>" onClick="javascript:ajouter_beneficiaire_remboursement();" style='font-size:10pt;' > </td>
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</tr>
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</tbody>
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</table>
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