<?php include ('header.php'); ?>


  <style type="text/css">
 
 .font-15{
  font-size: 15px !important;
 }

.carousel-indicators li
 {
    display: inline-block;
    width: 10px;
    height: 10px;
    margin: 1px;
    text-indent: -999px;
    cursor: pointer;
    background-color: #000 \9;
    background-color: rgba(16, 12, 12, 0.98);
    border: 1px solid #1d1b1b;
    border-radius: 10px;
}

 
 .red
 {
 	color:red;
 }
</style>
    <!--/#main-nav-->

 
    
  </header><!--/#home-->

 


 










    <!-- start -->
<section id="operation">
     <div class="container-fluid pb-80">
            <div class="section-title text-center">
          <div class="row">
            <div class="text-center col-sm-8 col-sm-offset-2 wow fadeInUp" data-wow-duration="1200ms" data-wow-delay="300ms" style="visibility: visible; animation-duration: 1200ms; animation-delay: 300ms; animation-name: fadeInUp;">
              <h3 class="text-uppercase mt-0"> Payment form </h3>
              <div class="title-icon">
                <i class="flaticon-charity-hand-holding-a-heart"></i>
              </div>
              <p><br /> </p>
            </div>
          </div>
        </div>

         
             <div class="container">
        <div class="row centered-form text-center">

        	<h3 class="panel-title"></h3>
			<p class="red"> Please fill all mandatory fields. </p>


        <div class="col-xs-12 col-sm-12 col-md-9 col-sm-offset-3">
        	<div class="panel panel-default">
        		<div class="panel-heading">
			    		
			 			</div>
			 			<div class="panel-body">
			    		  
			    			<form class="form-horizontal" name="payuform" action="<?php echo base_url()."payment/processing"; ?>" method="post">

                <input name="productinfo" type="hidden"  value="<?php echo $type ?>" readonly>

                <input name="amount" type="hidden"  value="<?php echo $amount ?>" readonly>
<fieldset>
 
 <div class="form-group">
  <label class="col-md-4 control-label font-15" for="textinput"> Donation Details: </label>  
  <div class="col-md-8" style="text-align: left;">
  
    <?php echo $type ?>
  </div>
</div>

<!-- Text input-->
<div class="form-group">
  <label class="col-md-4 control-label font-15" for="textinput">  Amount: </label>  
  <div class="col-md-4">
  
    <input type="text" placeholder="" class="form-control input-md" value="<?php echo $amount ?>" readonly required>
  </div>
</div>




<!-- Text input-->
<div class="form-group">
  <label class="col-md-4 control-label font-15" for="name"> Name *</label>  
  <div class="col-md-4">
  <input type="text" name="payname" class="form-control input-md" required>    
  </div>
</div>

<!-- Text input-->
<div class="form-group">
  <label class="col-md-4 control-label font-15" for="email"> Email *</label>  
  <div class="col-md-4">
  <input id="email" name="email" type="email" class="form-control input-md" required>    
  </div>
</div>


<!-- Text input-->
<div class="form-group">
  <label class="col-md-4 control-label font-15" for="pan"> PAN Card * </label>  
  <div class="col-md-4">
  <input type="text" name="paypan" class="form-control input-md">
    
  </div>
</div>


<!-- Text input-->
<div class="form-group">
  <label class="col-md-4 control-label font-15" for="phone">Phone *</label>  
  <div class="col-md-4">
  <input id="phone" name="phone" type="text" placeholder="" class="form-control input-md" required>
    
  </div>
</div>


<!-- Text input-->
<div class="form-group">
  <label class="col-md-4 control-label font-15" for="city">Address</label>  
  <div class="col-md-4">
  <input id="city" name="address" type="text" placeholder="" class="form-control input-md">
    
  </div>
</div>

<!-- Text input-->
<div class="form-group">
  <label class="col-md-4 control-label font-15" for="state">State</label>  
  <div class="col-md-4">
  <input id="state" name="state" type="text" placeholder="" class="form-control input-md" >
    
  </div>
</div>



<!-- Text input-->
<div class="form-group">
  <label class="col-md-4 control-label font-15" for="zipCode"> Country </label>  
  <div class="col-md-4">
  <input id="zipCode" name="country" type="text" placeholder="" class="form-control input-md" >
    
  </div>
</div>


 <div class="form-group">
<!-- <a href="#" class="btn btn-success font-15"> Submit </a> -->
<input type="submit" name="" class="btn btn-success font-15" value="submit">
<!-- <a href="#" class="btn btn-success font-15"> Submit </a> -->
 </div>

</fieldset>
</form>
			    	</div>
	    		</div>
    		</div>
    	</div>
    </div>  
                 
          </div>
                       
          
      
            
</div>

 
</section>













 

<?php include('footer.php');?>