source: pro-violet-viettel/sourcecode/application/modules/frontend/views/package_register_modal.php

<div class="modal fade" id="package_register_modal" tabindex="-1" role="dialog"aria-hidden="true">
    <div class="modal-dialog">
        <div class="modal-content">
            <div class="modal-header">
                <button type="button" class="close" data-dismiss="modal"><span aria-hidden="true">&times;</span><span class="sr-only">Close</span></button>
                <h4 class="modal-title">Đăng kÃœ gói dịch vụ</h4>
            </div>
            <div class="modal-body">

                <?php if ($can_buy == 0) { ?>
                    <div class="alert alert-block alert-success">       
                        <!--Số tiền trong Tà i khoản SBG Online hiện tại của QuÃœ vị là  <?php echo $user['acc_balanced']; ?> đồng.<br />
                        Tà i khoản chính của QuÃœ vị khÃŽng đủ để đăng kí sá»­ dụng cÃŽng cụ Soạn Bà i Giảng trá»±c tuyến trên soanbaigiang.smas.vn. Hãy nạp thêm tiền và  đăng kí lại. Cảm Æ¡n!-->
                                                <?php
                                                        $aryPatterns = array('/:acc_balanced:/');
                                                        echo preg_replace($aryPatterns, array($user['acc_balanced']), lang('_SBG_ACC_BALANCE_LESS_PACKAGE_PRICE_MSG'));
                                                ?>
                    </div>
                <?php } ?> 
                

                <?php if ($can_buy == 1) { ?>
                    <form id="do_package_register" class="form-horizontal" action="#" method="POST">
                        <input name="p_id" value="<?php echo $package['p_id']; ?>" type="hidden" />
                        <div class="errors" id="package_register_errors">
                            
                        </div>
                        <div class="form-group">
                            <label for="form-field-first" class="col-sm-4 control-label no-padding-right">
                                Họ và tên</label>
                            <div class="col-sm-8">
                                <input name="fullname" <?php if ($can_edit == 0) { ?>  disabled <?php } ?> type="text" value="<?php echo $info['fullname']; ?>" placeholder="Họ và tên" id="form-field-first" class="input-large">
                            <br />
                                    
                            </div>
                        </div>

                        <div class="space-4"></div>

                        <div class="form-group">
                            <label for="form-field-username" class="col-sm-4 control-label no-padding-right">
                                Đơn vị</label>
                            <div class="col-sm-8">
                                <input name="school" type="text" value="<?php echo $info['school']; ?>" placeholder="Đơn vị" id="form-field-first" class="input-large">
                            </div>
                        </div>
                                                <div class="form-group">
                                                        <label for="form-field-province" class="col-sm-4 control-label no-padding-right">Tỉnh / Thà nh phố</label>
                                                        <div class="col-sm-8">
                                                                <select name="province" id="form-field-province" class="form-field-province input-large">
                                                                        <option></option>
                                                                <?php foreach (lang('_PROVINCES_') as $key=>$pro):?>
                                                                        <option value="<?php echo $key;?>" <?php if($user['province'] == $key) echo "selected"; ?> ><?php echo $pro; ?></option>
                                                                <?php endforeach;?>
                                                                </select>
                                                        </div>
                                                </div>
                                                <div class="form-group">
                                                        <label for="form-field-username" class="col-sm-4 control-label no-padding-right">Quận / Huyện</label>
                                                        <div class="col-sm-8">
                                                                <select name="district" id="form-field-district" class="form-field-district input-large">
                        
                                                                </select>
                                                        </div>
                                                </div>

<?php if ($can_edit == 1) { ?>
                        Lưu Ü:
                        <ul> 
                        <li><?php echo lang('_SBG_USER_INFO_MSG'); ?></li><li><?php echo lang('_SBG_USER_FULLNAME_NOT_CHANGE_MSG'); ?></li>
                        </ul>
<?php } ?>
                        
                    </form>
                <?php } ?>
                <div class="modal-footer">
                    <?php if ($can_buy == 0) { ?>
                    <a id="package_register_back" class="btn btn-success" data-dismiss="modal">Nạp thêm tiền</a>
                    <?php } ?>
                        <?php if ($can_buy == 1) { ?>
                    
                        <a href="#" id="finish_package_register" class="btn btn-success" >Hoà n tất</a>
                    <?php } ?>
                </div>
            </div>
        </div>
    </div>
</div>