<?php
$page_title = "引落申請";
include_once('template/base_head.php');
?>
			<!-- サイドバー -->
			<aside id="colLeft">
				<h1><a href="/ja/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="pleft40 pb30">以下の内容で申請します。</p>
						<div class="pleft40">
						<form id="acForm" action="" method="post">
							<table class="table col bdr default odd requestT fontM mb40 ma90sp">
								<tr>
									<th>引落依頼先</th>
									<td><?php $this -> echoUserAccount(); ?> <?php $this -> echoName(); ?></td>
								</tr>
								<tr>
									<th>金額</th>
									<td><?php $this -> echoCurrency(); ?> <?php $this -> dispAmount(); ?></td>
								</tr>
								<tr>
									<th>メッセージ</th>
									<td><?php echo nl2br($this -> getRequestMessage()); ?></td>
								</tr>
							</table>

							<input type="hidden" value="" id="type" name="type" />

							<input type="hidden" value="<?php $this -> echoUserAccount(); ?>" id="account" name="account" />
							<input type="hidden" value="<?php $this -> echoCurrency(); ?>" id="currency" name="currency" />
							<input type="hidden" value="<?php $this -> echoAmount(); ?>" id="amount" name="amount" />
							<input type="hidden" value="<?php $this -> echoRequestMessage(); ?>" id="message" name="message" />
						</form>
						<p class="requestButton">
							<a href="#" id="btnBackInput" class="btn bg-default calign">&laquo; 戻る</a>&emsp;
							<input type="button" id="btnComplete" value="上記内容で申請" class="btn bg-grad px150 calign">
						</p>
								</div>
					</article>
				</div>
			</div>
			<!-- /メインカラム -->
		</div>
<?php include_once('template/base_foot.php'); ?>
	</div>
	<script src="../js/request.js"></script>
</body>
</html>
