000

<form action="<?php echo e(URL('/user/set-direct-collection')); ?>" method="post" role="form" id="editStatusForm">
<?php echo e(csrf_field()); ?>	
<div class="row">
	<input type="hidden" value="<?php echo e($retailer_id); ?>" name="retailer">
	<input type="hidden" value="<?php echo e($dealer_id); ?>" name="dealer">
		<input type="hidden" value="<?php echo e($user_id); ?>" name="user_id">
		
    
    
    
    
    
    <div class="col-md-12">
        <label for="status">Mode</label>
        <select name="mode" id="mode" class="form-control">
          <option value="Cash" selected>Cash</option>
            
        </select>
        <span class="label label-danger" id="mode" style="display: none;"></span>
        
    </div>
    <div class="col-md-12">
        <label for="remark">Amount</label>
          <input type="number" class="form-control" name="amount" value="">
       
    </div>
     <div class="col-md-12">
        <label for="remark">Reference no.</label>
        <textarea name="reference" id="reference" class="form-control"></textarea>
    </div>
     <div class="col-md-12">
        <label for="remark">Banknotes Denomination</label>
      <input type="number" class="form-control" name="one" value="" placeholder="2000" >
       <input type="number" class="form-control" name="two" value="" placeholder="500">
        <input type="number" class="form-control" name="three" value=""  placeholder="200">
        <input type="number" class="form-control" name="four" value="" placeholder="100">
          <input type="number" class="form-control" name="five" value="" placeholder="50">
           <input type="number" class="form-control" name="six" value="" placeholder="20">
            <input type="number" class="form-control" name="seven" value="" placeholder="10">
             <input type="number" class="form-control" name="eight" value="" placeholder="5">
              <input type="number" class="form-control" name="nine" value="" placeholder="2">
               <input type="number" class="form-control" name="ten" value="" placeholder="1">
    </div>
    </div>
    <div class="modal-footer">
        <button type="button" class="btn btn-default" data-dismiss="modal">Close</button>
        <button type="button" id="editCompanyBtn" class="btn btn-primary" >Submit</button>
    </div>
</form>