<div class="callout callout-success">
    @if($mode!="create")
        <div class="form-group">
            <div class="col-md-2">
                <div class="input-group mb-3 ">
                    <div class="input-group-prepend ">
                        <span class="input-group-text bg-success">N°</span>
                    </div>
                    <input readonly="readonly" type="text" class="form-control" name="id" id="id"
                                value='{!! str_pad($beneficiaire->id, 6, "0", STR_PAD_LEFT) !!}' />
                </div>
            </div>
        </div>
    @endif

    <div class="form-group row">
        <div class="col-md-5">
                {!! html()->label( 'Nom','nom') !!}
                {!! html()->text('nom', null)
                    ->placeholder('Nom')
                    ->attributes([($mode=="show"?'disabled':''), 'class' => 'form-control text-uppercase']) !!}
        </div>
        <div class="col-md-5">
                {!! html()->label( 'Prenom','prenom') !!}
                {!! html()->text('prenom', null)
                    ->placeholder('Prénom')
                    ->attributes([($mode=="show"?'disabled':''), 'class' => 'form-control']) !!}
        </div>
        <div class="col-md-2">
            {!! html()->label( 'Civilité','civilite') !!}
            {!! html()->select('civilite',['Mr'=>'Monsieur','Mme' => 'Madame', 'Mll' => 'Mademoiselle'],null)
                    ->placeholder('A définir')
                    ->attributes([($mode=="show"?'disabled':''),'class' => 'form-control'])  !!}
        </div>
    </div>

    <div class="form-group row">
        <div class="col-md-2">
            {!! html()->label( 'Date de naissance','datenaiss') !!}
                <div class='input-group date' id='datepicker_datenaiss'>
                    {!! html()->text('datenaiss', null)
                        ->placeholder('Date de naissance')
                        ->attributes([($mode=="show"?'disabled':''),'class' => 'form-control']) !!}
                    <span class='input-group-addon'><span class='glyphicon glyphicon-calendar'></span></span>

                </div>
        </div>
        <div class="col-md-4">
            {!! html()->label( 'Lieu de naissance','lieunaiss') !!}
            {!! html()->text('lieunaiss', null)
                ->placeholder('Lieu de naissance')
                ->attributes([($mode=="show"?'disabled':''), 'class' => 'form-control text-uppercase']) !!}
        </div>
    </div>

    <div class='form-group row'>
        <div class="col-md-3">
            {!! html()->label( 'Statut','statut') !!}
            {!! html()->select('statut',$liste_benefstatut,null)
                    ->placeholder('A définir')
                    ->attributes([($mode=="show"?'disabled':''),'class' => 'form-control'])  !!}
        </div>
        <div class='col-md-2'>
            {!! html()->label( 'Certificat de vie','n_all') !!}
            {!! html()->text('n_all', null)
                ->placeholder('Certificat de vie')
                ->attributes([($mode=="show"?'disabled':''),'class' => 'form-control']) !!}
        </div>
        <div class="col-md-2">
            {!! html()->label( 'date de décès','date_deces') !!}
            <div class='input-group date' id='datepicker_date_deces'>
                    {!! html()->text('date_deces', null)
                        ->placeholder('Date de décès')
                        ->attributes([($mode=="show"?'disabled':''),'class' => 'form-control']) !!}

                <span class='input-group-addon'><span class='glyphicon glyphicon-calendar'></span></span>

            </div>
        </div>
    </div>

    <div class='form-group row'>
        @if($mode!="create")
        <div class="col-md-3">
            {!! html()->label( 'Date de création','created_at') !!}
            {!! html()->text('created_at', null)->attributes(['readonly'=>'true','class' => 'form-control']) !!}
        </div>
        @endif

        <div class="col-md-2">
            {!! html()->label( 'Date 1ère immat.','date_pi') !!}
                <div class='input-group date' id='datepicker_datepi'>
                    {!! html()->text('date_pi', null)
                        ->placeholder('Date de première immatriculation')
                        ->attributes([($mode=="show"?'disabled':''),'class' => 'form-control']) !!}
                    <span class='input-group-addon'><span class='glyphicon glyphicon-calendar'></span></span>


                </div>
        </div>
    </div>

    <div class="form-group row" >
        <div class='col-md-4 '>
            {!! html()->label( 'Verrou','verrou') !!}
            {!! html()->checkbox('verrou', null,1)->attributes([($mode=="show"?'disabled':''),'class' => '']) !!}
        </div>
    </div>

    <div class='form-group row'>
        <div class="col-md-10" >
        {!! html()->label('Observations','obs',) !!}
        {!! html()->textarea('obs', null)->attributes([($mode=="show"?'disabled':''), 'class' => 'form-control', 'rows'=>'3']) !!}
        </div>
    </div>
</div>

