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Rev 33845 Rev 33885
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        </div>
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        </div>
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    </div>
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    </div>
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    <div class="col-md-12">
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    <div class="col-md-12">
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        <div class="container well">
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        <div class="container well">
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            <form name="Loi_Form" id="Loi_Form" method="post" style="margin-top:40px;">
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            <form name="loi-form" id="loi-form" method="post" style="margin-top:40px;">
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                <div class="row">
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                <div class="row">
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                    <div class="col-lg-3 form-group">
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                    <div class="col-lg-3 form-group">
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                        <label>Refer By(BGC Team)</label>
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                        <label>Refer By(BGC Team)</label>
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                        <select class="form-control type" name="referId" required>
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                        <select class="form-control type" name="referId" required>
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                        </div>
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                        </div>
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                    </div>
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                    </div>
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                </div>
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                </div>
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                ##                Agreed Brand fees (INR)
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                ##                Agreed Brand fees (INR)
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                <div class="row">
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                <div class="row">
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                    <div class="col-lg-3">
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                    <div class="col-lg-4">
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                        <div class="form-group">
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                        <div class="form-group">
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                            <label>Agreed Brand fees</label><span
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                            <label>Agreed Brand fees</label><span
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                                style="color:red ;font-size: 140%">*</span>
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                                style="color:red ;font-size: 140%">*</span>
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                            <select name="agreedBrandFees" class="form-control">
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                            <select name="agreedBrandFees" class="form-control">
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                                #foreach($storeTypeFeePair in $storeTypeFeePairs)
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                                #foreach($storeTypeFeePair in $storeTypeFeePairs)
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                            </select>
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                            </select>
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                        </div>
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                        </div>
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                    </div>
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                    </div>
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                    <!-- Brand fees collected (INR) -->
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                    <!-- Brand fees collected (INR) -->
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                    <div class="col-lg-2">
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                    <div class="col-lg-4">
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                        <div class="form-group">
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                        <div class="form-group">
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                            <label>Brand fees collected</label><span
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                            <label>Brand fees collected</label><span
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                                style="color:red ;font-size: 140%">*</span>
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                                style="color:red ;font-size: 140%">*</span>
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                            <input type="number" class="form-control " id="brandFeesCollected" required
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                            <input type="number" class="form-control " id="brandFeesCollected" required
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                                   name="brandFeesCollected" placeholder="500000">
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                                   name="brandFeesCollected" placeholder="500000">
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                        </div>
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                        </div>
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                    </div>
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                    </div>
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                    <!-- Mode of Payment Online/Cheque/IMPS/NEFT/RTGS/Wallet -->
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                    <!-- Mode of Payment Online/Cheque/IMPS/NEFT/RTGS/Wallet -->
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                    <div class="col-lg-2">
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                    <div class="col-lg-4">
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                        <div class="form-group">
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                        <div class="form-group">
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                            <label>Mode of Payment</label><span
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                            <label>Mode of Payment</label><span
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                                style="color:red ;font-size: 140%">*</span>
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                                style="color:red ;font-size: 140%">*</span>
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                            <select class="form-control" name="paymentMode" required>
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                            <select class="form-control" name="paymentMode" required>
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                                <option value="">Select mode</option>
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                                <option value="">Select mode</option>
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                                <option value="NEFT">NEFT</option>
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                                <option value="NEFT">NEFT</option>
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                                <option value="RTGS">RTGS</option>
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                                <option value="RTGS">RTGS</option>
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                            </select>
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                            </select>
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                        </div>
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                        </div>
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                    </div>
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                    </div>
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                </div>
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                    <!-- Payment reference no -->
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                    <!-- Payment reference no -->
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                <div class="row">
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                    <div class="col-lg-2">
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                    <div class="col-lg-4">
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                        <div class="form-group">
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                        <div class="form-group">
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                            <label>Payment Reference No</label><span
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                            <label>Payment Reference No</label><span
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                                style="color:red ;font-size: 140%">*</span>
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                                style="color:red ;font-size: 140%">*</span>
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                            <input type="text" class="form-control" id="paymentReferenceNo" required
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                            <input type="text" class="form-control" id="paymentReferenceNo" required
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                                   name="paymentReferenceNo" placeholder="">
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                                   name="paymentReferenceNo" placeholder="">
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                        </div>
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                        </div>
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                    </div>
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                    </div>
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                    <!-- fee collection date -->
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                    <!-- fee collection date -->
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                    <div class="col-lg-3">
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                    <div class="col-lg-4">
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                        <div class="form-group">
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                        <div class="form-group">
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                            <label>Fee collecting Date</label><span
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                            <label>Fee collecting Date</label><span
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                                style="color:red ;font-size: 140%">*</span>
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                                style="color:red ;font-size: 140%">*</span>
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                            <input type="datetime-local" class="form-control " id="feeCollectingDate" required
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                            <input type="datetime-local" class="form-control " id="feeCollectingDate" required
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                                   name="feeCollectingDate">
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                                   name="feeCollectingDate">
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                        </div>
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                        </div>
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                    </div>
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                    </div>
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                    <div class="col-lg-4">
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                        <div class="form-group">
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                            <label>Attach Screenshot</label><span
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                                style="color:red ;font-size: 140%">*</span>
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                            <input type="hidden" id="payment-sc-docId" name="paymentAttachment">
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                            <input type="file" class="form-control" id="payment-sc-doc" required>
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                        </div>
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                    </div>
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                </div>
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                </div>
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                <!-- Submit button-->
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                <!-- Submit button-->
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                <div class="form-group" style="text-align: center; margin-bottom:2px;">
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                <div class="form-group" style="text-align: center; margin-bottom:2px;">
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                    <button type="button"
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                    <button type="button"
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                            class="btn btn-primary text-white font-semibold py-1 px-4 rounded background-red submitLoiForm"
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                            class="btn btn-primary text-white font-semibold py-1 px-4 rounded background-red mk_submit_loi_form"
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                            style="box-shadow:none;margin-bottom:2px;">
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                            style="box-shadow:none;margin-bottom:2px;">
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                        <span>Submit</span>
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                        <span>Submit</span>
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                    </button>
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                    </button>
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                </div>
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                </div>
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            </form>
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            </form>