invisio v2.0

<?php
session_start();
include('../../../config/main_function.php');
$secure = "cAh3DrJACzw4RbU";
$connection = connectDB($secure);
$sql_pay_account = "SELECT * FROM tbl_bank WHERE active_status = '1' ";
$res_pay_account = mysqli_query($connection, $sql_pay_account);
$row_pay_account = mysqli_fetch_assoc($res_pay_account);
?>
<div class="modal-header">
    <h4 class="modal-title">Modal title</h4>
    <button type="button" class="close" data-dismiss="modal" aria-label="Close"><span aria-hidden="true">&times;</span></button>
</div>
<div class="modal-body">
    <div class="row">
        <div class="col-12">
            <label for="">ยอดรวม</label>
            xxx : บาท
        </div>
        <div class="col-12">
            <label for="">ส่วนลด</label>
            <input type="text" class="form-control" id="" name="" value="" placeholder="กรอกโค้ดส่วนลด">
        </div>
        <div class="col-12">
            <label for="">ยอดรวมสุทธิ</label>
            xxx : บาท
        </div>

</div>
    <div class="row">
        <form action="" id="payment_slip" enctype="multipart/form-data">

<div class="col-12 mb-2">
                <label for="" class="mb-2">หมายเลขบัญชีธนาคาร</label>
                <br>
                <div class="row">
                    <div class="col-3">
                        <img src="img/<?php echo $row_pay_account['logo']; ?>" alt="" class="mt-1" width="100px" height="100px">
                    </div>
                    <div class="col-9">
                        <label for=""><b>ธนาคาร</b> : <?php echo $row_pay_account['bank_name']; ?></label>
                        <br>
                        <label for=""><b>เลขที่บัญชี</b> : <?php echo $row_pay_account['account_number']; ?></label>
                        <br>
                        <label for=""><b>ชื่อบัญชี</b> : <?php echo $row_pay_account['account_name']; ?></label>
                    </div>
                </div>
            </div>

<div class="col-12 mb-2">
                <label for="" class="mb-2">แนบหลักฐานการชำระเงิน</label>
                <input type="file" class="form-control" name="slip_image" id="slip_image">
            </div>

<div class="col-12">
                <label for="">วันที่โอน</label>
                <div class="form-group" id="data_1">
                    <div class="input-group date">
                        <span class="input-group-addon"><i class="fa fa-calendar"></i></span>
                        <input type="text" class="form-control bg-white date" id="transfer_date" name="transfer_date" value="<?php echo date("d/m/Y") ?>" readonly>
                    </div>
                </div>
            </div>

<div class="col-12">
                <label for="">เวลาที่โอน</label>
            </div>
            <div class="col-12">
                <div class="row">
                    <div class="col-6 mb-2">
                        <select name="transfer_time_h" id="transfer_time_h" class="form-control">
                            <?php for ($i = 0; $i <= 23; $i++) : ?>
                                <option value="<?php echo str_pad($i, 2, "0", STR_PAD_LEFT); ?>" <?php if (date('H') == $i) : ?> selected <?php endif; ?>>
                                    <?php echo str_pad($i, 2, "0", STR_PAD_LEFT); ?>
                                </option>
                            <?php endfor; ?>
                        </select>
                    </div>

<div class="col-6 mb-2">
                        <select name="transfer_time_m" id="transfer_time_m" class="form-control">
                            <?php for ($i = 0; $i <= 59; $i++) : ?>
                                <option value="<?php echo str_pad($i, 2, "0", STR_PAD_LEFT); ?>" <?php if (date('i') == $i) : ?> selected <?php endif; ?>>
                                    <?php echo str_pad($i, 2, "0", STR_PAD_LEFT); ?>
                                </option>
                            <?php endfor; ?>
                        </select>
                    </div>
                </div>
            </div>
            <div class="col-12">
                <label for="" class="">หมายเหตุ</label>
                <textarea name="payment_remark" id="payment_remark" cols="30" rows="3" class="form-control mb-2"></textarea>
                
            </div>
        </form>
    </div>
</div>
<div class="modal-footer">
    <button type="button" class="btn btn-primary" onclick="NewReceipt()"><i class="fa fa-check"></i>&nbsp;บันทึก</button>
    <button type="button" class="btn btn-white" data-dismiss="modal">ปิด</button>
</div>