<?php include '../../layouts/header.php';?>
 <!-- Content Wrapper. Contains page content -->
  <div class="content-wrapper">
    <!-- Content Header (Page header) -->
    <div class="content-header">
      <div class="container-fluid">
        <div class="row mb-2">
          <div class="col-sm-6">
            <h1 class="m-0">PICKUP REQUEST - MANUAL </h1>
          </div><!-- /.col -->
          <div class="col-sm-6">
            <ol class="breadcrumb float-sm-right">
              <li class="breadcrumb-item"><a href=" #">TRANSACTION </a></li>
              <li class="breadcrumb-item active">  REVERSE PICKUP </li>
            </ol>
          </div><!-- /.col -->
        </div><!-- /.row -->
      </div><!-- /.container-fluid -->
    </div>
    <!-- /.content-header -->
    <!-- Main content -->
    <section class="content">
      <div class="container-fluid">
        <!-- form -->
        <div class="row">
          <!-- left column -->
          <div class="col-md-12">
            <!-- general form elements -->
            <div class="card card-primary">
              <div class="card-header">
                <h3 class="card-title">PICKUP REQUEST - MANUAL  </h3>
              </div>
              <!-- /.card-header -->
              <!-- form start -->
              <form class="form-horizontal">
                <div class="card-body">
                  <div class="form-group row">
                    <label  class="col-sm-2 col-form-label">Request No	</label>
                    <div class="col-sm-4"> 
                    <input type="text" class="form-control form-control-sm">
                    </div>  
                    <label class="col-sm-2 col-form-label">	Reference No	</label>
                    <div class="col-sm-4">
                    <input type="text" class="form-control form-control-sm">
                    </div> </div> 
                    <div class="form-group row">
                    <label class="col-sm-2 col-form-label">Office Name		</label>
                    <div class="col-sm-4">
                    <input type="text" class="form-control form-control-sm">
                    </div>   
                    <label  class="col-sm-2 col-form-label">	Shipper Name</label>
                    <div class="col-sm-4"> 
                    <input type="text" class="form-control form-control-sm">
                    </div>  
                    </div>
                    <div class="form-group row">
                    <label  class="col-sm-2 col-form-label">Product Name	 </label>
                    <div class="col-sm-2"> 
                    <select class="form-control">
                    <option>CARGO</option>
                                                    <option>CASH PICKUP</option>
                                                    <option>CHEQUE PICKUP</option>
                                                    <option>COD</option>
                                                    <option>COURIER LAPTOP</option>
                                                    <option>COURIER PICKUP</option>
                                                    <option>ELECTRONIC GODDS</option>
                                                    <option>ELECTRONIC GOODS</option>
                                                    <option>FILE PICKUP</option>
                                                    <option>FTL</option>
                                                    <option>KYC</option>
                                                    <option>MEDICAL GOODS</option>
                                                    <option>PREPAID</option>
                                                    <option>REVERSE PICKUP</option>
                                                    <option>STATIONERY</option>
                                                    <option>V2 ~ ELECTRONIC GODDS</option>
                    </select>
                    </div>  
                    <label class="col-sm-1 col-form-label">Mode </label>
                    <div class="col-sm-2">
                    <select class="form-control">
                    <option>AIR</option>
                                                  <option>SURFACE</option>
                                                  <option>RAIL</option>
                                                  </select>
                    </div> 
                    <label  class="col-sm-2 col-form-label"> Pickup Date & Time</label>
                    <div class="col-sm-3"> 
                    <input type="text" class="form-control form-control-sm">
                    </div> 
                    </div> 
                    <div class="row">
                    <div class="col-md-12">
                     <div class="card card-primary">
              <div class="card-header" style="background-color: #fff;color: black;">
                <h3 class="card-title"  style="color:#d13d11; font-weight:800;">GENERAL DETAIL</h3>
              </div>   
              <div class="row">
              <div class="card-body">
                  <div class="row">
                  <div class="col-md-">
                    <div class="form-group">
                    <label>Person Name	</label>
                    <input type="text" class="form-control form-control-sm"  >
                  </div>
                </div> 
                  <div class="col-md-2">
                  <div class="form-group">
                    <label >Pincode</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>
                <div class="col-md-2">
                  <div class="form-group">
                    <label >Length</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>
                <div class="col-md-1">
                  <div class="form-group">
                    <label >Width</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>
                 
                  <div class="col-md-1">
                  <div class="form-group">
                    <label >Height</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>
                <div class="col-md-2">
                  <div class="form-group">
                    <label >Risk Value	</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>
                <div class="col-md-2">
                  <div class="form-group">
                    <label >Goods Value		</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>  
                <div class="col-md-5">
                  <div class="form-group">
                    <label >Contents</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>
                <div class="col-md-2">
                  <div class="form-group">
                    <label >SKU ID</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>
                <div class="col-md-5">
                  <div class="form-group">
                    <label > Return Reason</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>
                <div class="col-md-2">
                  <div class="form-group">
                    <label >Cheque Amount	</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>
                <div class="col-md-2">
                  <div class="form-group">
                    <label >Ecs Form	</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div> 
            </div>
            </div> 
                  </div>
                  </div>
                </div>  
                  </div>
                  </div>  
                </div>
                <div class="row">
                    <div class="col-md-6">
                     <div class="card card-primary">
              <div class="card-header" style="background-color: #fff;color: black;">
                <h3 class="card-title"  style="color:#d13d11; font-weight:800;">PICKUP DETAIL</h3>
              </div>   
              <div class="row">
              <div class="card-body">
                  <div class="row">
                  <div class="col-md-10">
                    <div class="form-group">
                    <label>Person Name	</label>
                    <input type="text" class="form-control form-control-sm"  >
                  </div>
                </div> 
                  <div class="col-md-2">
                  <div class="form-group">
                    <label >Pincode</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>
                <div class="col-md-12">
                  <div class="form-group">
                    <label >Address1</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>
                <div class="col-md-12">
                  <div class="form-group">
                    <label >Address2</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div> 
                  <div class="col-md-6">
                  <div class="form-group">
                    <label >Mobile</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>
                <div class="col-md-6">
                  <div class="form-group">
                    <label >Phone </label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div> 
                  <div class="col-md-6">
                  <div class="form-group">
                    <label >Email</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>
                <div class="col-md-3">
                  <div class="form-group">
                    <label >City </label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div> 
                  <div class="col-md-3">
                  <div class="form-group">
                    <label >State</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>
            </div>
            </div> 
                  </div>
                  </div>
                </div>
                <div class="col-md-6">
                     <div class="card card-primary">
              <div class="card-header" style="background-color: #fff;color: black;">
                <h3 class="card-title"  style="color:#d13d11; font-weight:800;">DELIVERY DETAIL</h3>
              </div>   
              <div class="card-body">
              <div class="row">
                    <div class="col-md-10">
                    <div class="form-group">
                    <label>Person Name	</label>
                    <input type="text" class="form-control form-control-sm"  >
                  </div>
                  </div>
                  <div class="col-md-2">
                    <div class="form-group">
                    <label>Pincode</label>
                    <input type="text" class="form-control form-control-sm">
                  </div>
                  </div>
                  <div class="col-md-12">
                  <div class="form-group">
                    <label >Address1</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>
                <div class="col-md-12">
                  <div class="form-group">
                    <label >Address2</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div> 
                  <div class="col-md-6">
                  <div class="form-group">
                    <label >Mobile</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>
                <div class="col-md-6">
                  <div class="form-group">
                    <label >Phone </label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div> 
                  <div class="col-md-6">
                  <div class="form-group">
                    <label >Email</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>
                <div class="col-md-3">
                  <div class="form-group">
                    <label >City </label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div> 
                  <div class="col-md-3">
                  <div class="form-group">
                    <label >State</label>
                    <input type="text" class="form-control form-control-sm" >
                  </div>
                </div>
                  </div> 
                  </div>
                  </div>  
                </div>
                <!-- /.card-body -->
                <div class="card-footer">
                  <button type="submit" class="btn btn-info">Save</button>
                </div>
                <!-- /.card-footer -->
              </form> 
            </div>
          </div>
            </div>
        </div>
        <!-- form -->
      </div><!-- /.container-fluid -->
    </section>
    <!-- /.content -->
  </div>
  <!-- /.content-wrapper -->
  <?php include '../../layouts/footer1.php';?>  