<%@ Page Title="Fulfillment Wizard - Receipt" Language="C#" AutoEventWireup="true"
    Culture="auto" UICulture="auto" CodeBehind="Receipt.aspx.cs" Inherits="WebSite.site.HITS.Claims.Wizard.Fulfillment.Receipt" %>

<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head id="Head1" runat="server">
</head>
<body>
    <form id="form1" runat="server">
    <table style="width: 800px; font-family: Verdana; font-size: 12px">
        <tr>
            <td align="left">
            </td>
            <td align="right">
                <input id="m_btnPrint" type="button" value=" Print " onclick="window.print(); return false;" />
            </td>
        </tr>
        <tr>
            <td align="left">
                <img src="../../../../../images/ReceiptLogo.png" style="height: 93px; width: 243px" />
            </td>
            <td align="right">
            </td>
        </tr>
        <tr>
            <td align="left">
            </td>
            <td align="right">
                <asp:Label ID="DescriptionLabel" runat="server" Font-Bold="true" Text="<%$ Resources : FulfillmentManagement, LabelReceiptDescription %>" />
            </td>
        </tr>
        <tr>
            <td align="left">
            </td>
            <td align="right">
                <asp:Label ID="StoreLocationLabel" runat="server" Font-Bold="true" Text="<%$ Resources : FulfillmentManagement, LabelStoreLocation %>" />
            </td>
        </tr>
        <tr>
            <td align="left">
            </td>
            <td align="right">
                <asp:Label ID="DateLabel" runat="server" Font-Bold="true" Text="Date:" />
            </td>
        </tr>
        <tr>
            <td align="left">
                <asp:Label ID="NameLabel" runat="server" Font-Bold="true" Text="Name:" />
            </td>
            <td align="right">
            </td>
        </tr>
        <tr>
            <td align="left">
                <asp:Label ID="MDNLabel" runat="server" Font-Bold="true" Text="MDN:" />
            </td>
            <td align="right">
            </td>
        </tr>
        <tr>
            <td align="left">
                <asp:Label ID="ClaimIDLabel" runat="server" Font-Bold="true" Text="Claim ID:" />
            </td>
            <td align="right">
            </td>
        </tr>
        <tr>
            <td align="left">
                <asp:Label ID="DeductibleLabel" runat="server" Font-Bold="true" Text="Deductible amount:" />
            </td>
            <td align="right">
            </td>
        </tr>
        <tr>
            <td align="left">
                <asp:Label ID="AmountPaidLabel" runat="server" Font-Bold="true" Text="<%$ Resources : FulfillmentManagement, LabelAmountPaid %>" />
            </td>
            <td align="right">
                <asp:Label ID="AmountLabel" runat="server" Font-Bold="true" />
            </td>
        </tr>
        <tr>
            <td align="left">
                <asp:Label ID="MethodOfPaymentLabel" runat="server" Font-Bold="true" Text="<%$ Resources : FulfillmentManagement, LabelMethodOfPayment %>" />
            </td>
            <td align="right">
                <asp:Label ID="PaymentMethodLabel" runat="server" Font-Bold="true" />
            </td>
        </tr>
        <tr>
            <td align="left">
                <asp:Label ID="PaymentStatusLabel" runat="server" Font-Bold="true" Text="<%$ Resources : FulfillmentManagement, LabelPaymentStatus %>" />
            </td>
            <td align="right">
                <asp:Label ID="StatusLabel" runat="server" Font-Bold="true" />
            </td>
        </tr>
        <tr>
            <td align="left" colspan="2">
                <asp:Literal ID="PaymentFooterLiteral" runat="server" Text="<%$ Resources : FulfillmentManagement, LiteralPaymentFooter %>" />
            </td>
        </tr>
    </table>
    </form>
</body>
</html>
