<?
$this->load->view('cpanel/header');
?>

		<script src="<?=base_url()?>js/jquery.validationEngine-en.js" type="text/javascript"></script>
		<script src="<?=base_url()?>js/jquery.validationEngine.js" type="text/javascript"></script>



		<script>
		$(document).ready(function() {


			$("#formID").validationEngine()


			//$.validationEngine.loadValidation("#date")
			//alert($("#formID").validationEngine({returnIsValid:true}))
			//$.validationEngine.buildPrompt("#date","This is an example","error")	 		 // Exterior prompt build example
			//$.validationEngine.closePrompt(".formError",true) 							// CLOSE ALL OPEN PROMPTS
		});

	</script>



<form id="formID"  method="post" action="<?=site_url('gateway/addEditProvider')?>">

<input type='hidden' name='id' id='id' value='<?= $id; ?>' >
<input type='hidden' name='action' id='action' value='<?= $action; ?>' >

<table width="80%" border="0" align="center" cellpadding="0" cellspacing="0">

  <tr>
    <td colspan="2" valign="top" style="padding-top:20px;">

      <img src="<?=base_url()?>images/s.gif" width="600" height="1" border="0" alt="" />
      <div id="module_info">

                  <span>»</span> <?=$titleMessage?>  <?=$titleErrorMessage?>  </div>

    </td>
  </tr>

  <tr>
    <td colspan="2" valign="top" style="padding-top:10px;padding-right:5px;">
    <!-- Account Information -->

<table width="100%" class="tableBorder" border="0"  cellpadding="2" cellspacing="2">
  <tr>
    <td colspan="2" class="mainTableTitle"><?=TITLE029?></td>
  </tr>

<tr>
	<td class='formLabelRigit' width='30%' style='padding-top:10px;'>  Provider Name :  </td>
	<td class='formLabelLeft' width='70%' style='padding-top:10px;'><input type='text' class='validate[required,length[6,30]] formInput' name='provider_name' id='provider_name' style='width:200px;' value='<?= $provider_name; ?>' /></td>
</tr>

<tr>
	<td class='formLabelRigit' width='30%'>  Description :  </td>
	<td class='formLabelLeft' width='70%'><input type='text' class='formInput' name='description' id='description' style='width:200px;' value='<?= $description; ?>' /></td>
</tr>

<tr>
	<td class='formLabelRigit' width='30%'>  Contact Name :  </td>
	<td class='formLabelLeft' width='70%'><input type='text' class='formInput' name='contact_name' id='contact_name' style='width:200px;' value='<?= $contact_name; ?>' /></td>
</tr>

<tr>
	<td class='formLabelRigit' width='30%'>  Contact Email :  </td>
	<td class='formLabelLeft' width='70%'><input type='text' class='formInput' name='contact_email' id='contact_email' style='width:200px;' value='<?= $contact_email; ?>' /></td>
</tr>

<tr>
	<td class='formLabelRigit' width='30%'>  Contact Phone :  </td>
	<td class='formLabelLeft' width='70%'><input type='text' class='formInput' name='contact_phone' id='contact_phone' style='width:200px;' value='<?= $contact_phone; ?>' /></td>
</tr>

<tr>
	<td class='formLabelRigit' width='30%'>  Office Phone :  </td>
	<td class='formLabelLeft' width='70%'><input type='text' class='formInput' name='office_phone' id='office_phone' style='width:200px;' value='<?= $office_phone; ?>' /></td>
</tr>

<tr>
	<td class='formLabelRigit' width='30%'>  Office Email :  </td>
	<td class='formLabelLeft' width='70%'><input type='text' class='formInput' name='office_email' id='office_email' style='width:200px;' value='<?= $office_email; ?>' /></td>
</tr>

<tr>
	<td class='formLabelRigit' width='30%'>  Address :  </td>
	<td class='formLabelLeft' width='70%'><input type='text' class='formInput' name='office_address' id='office_address' style='width:200px;' value='<?= $office_address; ?>' /></td>
</tr>



  <tr>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
  </tr>
</table>

 </td>

  </tr>


  <tr>
    <td colspan="2" align="center" style="padding:15px;"><input type="submit" class="submit_but" name="submit" value="<?= $action == 'Add' ? " Submit Now " : "Edit Now" ?>" class="input-submit" /></td>
  </tr>


  <tr>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
  </tr>
  <tr>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
  </tr>
</table>

</form>



<?
$this->load->view('cpanel/left_nemu');
$this->load->view('cpanel/footer');
?>
