Please fill this form after making payment

Agent payment alert form

SHOP NAME (*)	Invalid Input
Agent Name (*)	Invalid Input
Login ID (*)	Invalid Input
Teller Number (*)	Invalid Input
Bank Of deposit (*)	Invalid Input	Which bank did you pay to?
Name Of Depositor (*)	Invalid Input
Amount Paid In (*)	Invalid Input
Purpose Of Payment (*)	Choose PurposePrepaid Shop CreditWeekly Remittance Invalid Input
Date Of payment (*)	Invalid Input
Current Phone Number (*)	Invalid Input
Comment	Invalid Input
captcha (*)	Invalid Input	fill this
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