PAL.C.T MINI SHELL
<div class='news_tittle'>
<h4> Konfirmasi Pembayaran </h4>
</div>
<div class="col-md-12">
<b>Telah dilakukan pembayaran dengan </b>
<form role="form" method="POST" class="form-horizontal" action="konfirmasi.php" enctype='multipart/form-data'>
<div class="form-group">
<label class="col-sm-3 control-label" ><span class='red'>*</span>Invoice</label>
<div class="col-sm-8">
<input name="no_invoice" type="text" placeholder="No. Invoice" class="form-control" required>
</div>
</div>
<div class="form-group">
<label class="col-sm-3 control-label" ><span class='red'>*</span>Ke Bank</label>
<div class="col-sm-8">
<select name='bank' class="form-control">
<?php
$tampil=mysql_query("SELECT * FROM bank ORDER BY nama_bank ASC");
$no=1;
while ($r=mysql_fetch_array($tampil)){
echo "<option value='$r[nama_bank]'> $r[nama_bank] </option>";
}
?>
</select>
</div>
</div>
<div class="form-group">
<label class="col-sm-3 control-label" ><span class='red'>*</span>Sejumlah</label>
<div class="col-sm-8">
<input name="jumlah" type="text" placeholder="jumlah yang di bayar" class="form-control" required>
</div>
</div>
<div class="form-group">
<div class="col-sm-offset-3 col-sm-9">
<button class="btn btn-primary" type="submit">Submit</button>
<br><br><i>Note : Form yang bertanda <span class='red'>*</span> harus di isi.</i>
</div>
</div>
</form>
</div>
<br><br>
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