<?php
$page_title = "iWallet卡-申請";
include_once('template/base_head.php');
?>
			<!-- サイドバー -->
			<aside id="colLeft">
				<h1><a href="/tc/menu"><img src="../img/logo.png" alt="iWallet"></a></h1>
<?php include_once('template/base_sidebar.php'); ?>
			</aside>
			<!-- /サイドバー -->
			<!-- メインカラム -->
			<div id="colMain">
				<div class="mainIn">
<?php include_once('template/base_nav.php'); ?>
					<article>
						<div class="article-heading">
							<h2><?php echo $page_title; ?></h2>
						</div>

						<p class="mb20 pleft40">請確認您輸入的內容後點擊提交。</p>
						<?php $this -> echoMessage(); ?>
						<form id="acForm" action="" method="post" class="pleft40 pb40">
							<table class="table col bdr default odd calign w99p fontXS mb20" id="table-breakpoint">
								<tr>
									<th class="w30p">申請數量</th>
									<td class="w70p l"><?php $this -> echoIndex(); ?>piece(s)</td>
								</tr>
								<tr>
									<th class="w30p">預付卡卡種</th>
									<td class="w70p l"><?php $this -> dispCardLimit(); ?></td>
								</tr>
								<tr>
									<th class="w30p">使用上限</th>
									<td class="w70p l"><?php $this -> echoSippingName(); ?></td>
								</tr>
								<tr>
									<th class="w30p">國家</th>
									<td class="w70p l"><?php $this -> dispCountry(); ?></td>
								</tr>
								<tr>
									<th class="w30p">省</th>
									<td class="w70p l"><?php $this -> echoState(VAL_INT_2); ?></td>
								</tr>
								<tr>
									<th class="w30p">縣/市</th>
									<td class="w70p l"><?php $this -> echoCity(VAL_INT_2); ?></td>
								</tr>
								<tr>
									<th class="w30p">地址</th>
									<td class="w70p l"><?php $this -> echoAddress(VAL_INT_2); ?></td>
								</tr>
								<tr>
									<th class="w30p">郵遞區號</th>
									<td class="w70p l"><?php $this -> echoZipCode(VAL_INT_2); ?></td>
								</tr>
								<tr>
									<th class="w30p">聯繫電話</th>
									<td class="w70p l"><?php $this -> echoTel(VAL_INT_2); ?></td>
								</tr>
							</table>
							<p class="calign">
								<a href="#" id="btnBackInput" class="btn bg-default">&laquo; 返回</a>&emsp;
								<input type="button" id="btnComplete" value="確認申請" class="btn bg-grad px150">
							</p>
							<input type="hidden" id="type" name="type" value="" />

							<input type="hidden" id="index" name="index" value="<?php $this -> echoIndex(); ?>" />
							<input type="hidden" id="sip_flg" name="sip_flg" value="<?php $this -> echoSipFlg(); ?>" />
							<input type="hidden" id="country" name="country" value="<?php $this -> echoCountry(); ?>" />
							<input type="hidden" id="state" name="state" value="<?php $this -> echoState(VAL_INT_1); ?>" />
							<input type="hidden" id="city" name="city" value="<?php $this -> echoCity(VAL_INT_1); ?>" />
							<input type="hidden" id="address" name="address" value="<?php $this -> echoAddress(VAL_INT_1); ?>" />
							<input type="hidden" id="zip_code" name="zip_code" value="<?php $this -> echoZipCode(VAL_INT_1); ?>" />
							<input type="hidden" id="tel" name="tel" value="<?php $this -> echoTel(VAL_INT_1); ?>" />
						</form>
					</article>
				</div>
			</div>
			<!-- /メインカラム -->
		</div>
<?php include_once('template/base_foot.php'); ?>
	</div>
	<script src="../js/card_apply.js"></script>
</body>
</html>
