<?php
if (!defined('FLUX_ROOT')) exit;

$markdownURL = 'http://daringfireball.net/projects/markdown/syntax';
?>


<h2>Donation Validation Request</h2>
<?php if (!empty($errorMessage)): ?>
	<p class="red"><?php echo htmlspecialchars($errorMessage) ?></p>
<?php else: ?>
	<p>	
		Please fill-up the form below, we will send the claim code via mobile phone you enter below.  
		Our validation team will check on this record as soon as we receive it.
	</p>
<?php endif ?>

<form action="<?php echo $this->urlWithQs ?>" method="post" name="mailerform" class="generic-form" >
	<input type="hidden" name="to" value="<?php echo htmlspecialchars(Flux::config('DonationEmail')) ?>" />
	<input type="hidden" name="subject" value="Donation Processing Request" />
	<?php echo Flux_Security::csrfGenerate('Mailer', true) ?>
	<table class="generic-form-table">
		<tr>
			<th><label>Donation Option:</label></th>
			<td>
  				<select name="option">
 				    <option value="7 Eleven">7 Eleven</option>	
   				</select>
			</td>
		</tr>
		<tr>
			<th><label for="name">Name</label></th>
			<td><input type="text" name="name" id="subject" value="<?php echo htmlspecialchars($params->get('name')) ?>" /></td>
		</tr>
		<tr>
			<th><label for="name">Amount</label></th>
			<td><input type="text" name="amount" id="subject" value="<?php echo htmlspecialchars($params->get('amount')) ?>" /></td>
		</tr>
		<tr>
			<th><label for="name">Reference</label></th>
			<td><input type="text" name="reference" id="subject" value="<?php echo htmlspecialchars($params->get('reference')) ?>" /></td>
		</tr>
		<tr>
			<th><label for="name">Mobile Phone</label></th>
			<td><input type="text" name="mobile" id="subject" value="<?php echo htmlspecialchars($params->get('mobile')) ?>" /></td>
		</tr>
		<tr>
			<td colspan="2" align="right">
				<input type="submit" value="Submit Request" />
				
			</td>
		</tr>
	</table>
</form>
  </div>
</div>
