
<main class="app-content">
<div class="app-title">
  <div>

    <h1><i class="fa fa-th-list"></i>Service name</h1>
  </div>
  <ul class="app-breadcrumb breadcrumb">
    <li class="breadcrumb-item"><i class="fa fa-home fa-lg"></i></li>
    <li class="breadcrumb-item"></li>
    <li class="breadcrumb-item active"><a href="#">Home</a></li>
  </ul>
</div>
<div class="row">
  
  <div class="col-md-12">
    <div class="col-md-8">
      <div class="tile">
        <h3 class="tile-title"></h3>
		  <form method="post" action="">
        <div class="tile-body">
          
			 <div class="form-group">
              <label class="control-label">Name</label>
              <input class="form-control" type="text" name="user_name" value="" placeholder="Name">
				  <input  type="hidden" name="user_id" value="" >
            </div>
			 <div class="form-group">
              <label class="control-label">Bill Number</label>
              <input class="form-control" type="text" name="bill" value="" placeholder="Billing Number">
            </div>
            <div class="form-group">
              <label class="control-label">Plan Name</label>
              <input class="form-control" type="text" name="plan_name" value="" placeholder="Plan Name">
				 <input  type="hidden" name="plan_id" value="" >
            </div>
			  <div class="form-group">
              <label class="control-label">Amount</label>
              <input class="form-control" type="text" name="price" value="" placeholder="Amount">
            </div>
           
             <div class="form-group">
              <label class="control-label">Payment Date </label>
              <input class="form-control" type="date" name="pay_date" value="" placeholder="Price">
            </div>
			 <div class="form-group">
              <label class="control-label">Account Number</label>
              <input class="form-control" type="text" name="accno" value="" placeholder="A/C No.">
            </div>
           
          
               
                  </div>
                </div>
              </div>
             
              
              
             
             
              
             
              
            </div>
          
        </div>
        <div class="tile-footer">
		
          <button class="btn btn-primary" type="submit" name="submit_btn"><i class="fa fa-fw fa-lg fa-check-circle"></i>Add Now</button>
			
			&nbsp;&nbsp;&nbsp;
		
			<a class="btn btn-secondary" href="#"><i class="fa fa-fw fa-lg fa-times-circle"></i>Cancel</a>
        </div>
			</form>
      </div>
    </div>
  </div>
</div>
</main>
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