<?php
$page_title = "Payment Request Form";
include_once('template/base_head.php');
?>
			<!-- サイドバー -->
			<aside id="colLeft" class="login">
				<h1><a href=""><img src="../img/logo.png" alt="iWallet"></a></h1>
				<h2></h2>
				<div class="sideLogin"></div>
			</aside>
			<!-- /サイドバー -->
			<!-- メインカラム -->
			<div id="colMain" class="nonav">
				<div class="mainIn">
<?php include_once('template/base_nav_white.php'); ?>
					<article>
						<div class="article-heading">
							<h2><?php echo $page_title; ?></h2>
						</div>
						<?php $this -> echoMessage(); ?>
						<form id="acForm" action="" method="post">

						<p class="mb30">Please choose your payout currency, click confirm after indicating your message.</p>

						<!-- /デザインスペース -->
						
						<div class="clearfix shelfD">
							<div class="dt250 font14">Requestee Account Number</div>
								<?php $this -> echoToAccount(); ?>
						</div>
						<div class="clearfix shelfD">
							<div class="dt250 font14">Requestee Name</div>
								<?php $this -> dispSiteName(); ?>
						</div>
						<div class="clearfix shelfD">
							<div class="dt250 font14">Product</div>
								<?php $this -> echoTitle(); ?>
						</div>
						<div class="clearfix shelfD">
							<div class="dt250 font14">Amount Received</div>
								<?php $this -> echoCurrency(); ?> <?php $this -> echoAmount(); ?>
						</div>
						<div class="clearfix shelfD">
							<div class="dt250 font14">Please specify the payout currency.</div>
										<select id="debit_currency" name="debit_currency" class="px80">
											<?php $this -> dispCurrency(); ?>
										</select>&emsp;
										<input type="button" id="btnBalance" name="btnBalance" value="Balance Check" class="btn bg-grad px150">
										<span id="balanceCurrency"></span>
						</div>
						<div class="clearfix shelfD">
							<div class="dt250 font14">Message</div>
								<textarea rows="3" cols="40" id="message" name="message" class="w40p lalign"><?php $this -> echoMsg(); ?></textarea>
						</div>
						

							<input type="hidden" value="input" id="type" name="type" />
							<input type="hidden" value="<?php $this -> echoUserAccount(); ?>" id="from_account" name="from_account" />

							<input type="hidden" value="<?php $this -> echoSignature(); ?>" id="signature" name="signature" />
							<input type="hidden" value="<?php $this -> echoToAccount(); ?>" id="user_account" name="user_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 -> echoTitle(); ?>" id="title" name="title" />

							<input type="hidden" value="<?php $this -> echoSuccessUrl(); ?>" name="success_url" />
							<input type="hidden" value="<?php $this -> echoFailUrl(); ?>" name="fail_url" />
							<input type="hidden" value="<?php $this -> echoCancelUrl(); ?>" name="cancel_url" />
							<input type="hidden" value="<?php $this -> echoReturnUrl(); ?>" name="return_url" />
							<input type="hidden" value="<?php $this -> echoPNum(); ?>" name="p_num" />

							<?php $this -> echoParams(); ?>
							<div class="dt250 noborder"></div>
							<p class=""><input type="button" id="btnConfirm" name="btnCardConfirm" value="Confirm" class="btn bg-parent px150"></p>

						</form>
					</article>
				</div>
			</div>
			<!-- /メインカラム -->
		</div>
<?php include_once('template/base_foot.php'); ?>
	</div>
	<script src="../js/settlement.js"></script>
</body>
</html>
