<form class="form-horizontal" action="data/form_cadastra_devolucao.php" method="POST">
                                    <input type="hidden" id="cliente" name="cliente" value="<?php echo $cliente ; ?>">
                                    <input type="hidden" id="nome"    name="nome"    value="<?php echo $nome ; ?>">
                                    <div class="comtainer">
                                        <div class="row">
                                            <div class="col-md-6">
                                                <label for="data">Data:</label>
                                                <input type="date" class="form-control" id="data" name="data" required>
                                            </div>

                                            <div class="col-md-6">
                                                <label for="loja">Loja:</label>
                                                <select class="form-control" id="loja" name="loja" required>
                                                    <option ></option>
                                                    <option value="1">1</option>
                                                    <option value="2">2</option>
                                                    <option value="3">3</option>
                                                    <option value="4">4</option>
                                                </select>

                                            </div>
                                        </div>
                                    </div>
                                    <br>
                                    <div class="row">
                                        <div class="col-md-6">
                                            <label for="pdv">Pdv:</label>
                                            <input type="text" class="form-control" id="pdv" name="pdv" required>
                                        </div>
                                        <div class="col-md-5">
                                            <label for="cupom">Cupom:</label>
                                            <input type="text" class="form-control" id="cupom" name="cupom" required>
                                        </div>
                                        <div class="col-md-1">
                                            <a data-toggle="modal" href="#modalItensCupom">VALIDAR</a>
                                        </div>
                                    </div>
                                    <br>
                                    <label for="motivo">Motivo:</label>
                                    <textarea class="form-control" rows="5" id="motivo" name="motivo"></textarea>
                                    <br>
                                    <button type="submit" class="btn btn-primary" style="float: right;"><span class="glyphicon glyphicon-ok"></span> CADASTRAR</button>
                                </form>

<!-- Modal -->
        <div class="modal fade" id="modalItensCupom" role="dialog">
            <div class="modal-dialog">

                <!-- Modal content-->
                <div class="modal-content">
                    <div class="modal-header">
                        <button type="button" class="close" data-dismiss="modal">&times;</button>
                        <h4 class="modal-title">CUPOM <div id="rcupom"></div></h4>
                    </div>
                    <div class="modal-body">
                        <p id="rdata"></p>
                        <p id="rloja"></p>
                        <p id="rpdv"></p>
                        <p id="rcupom"></p>
                    </div>
                    <div class="modal-footer">
                        <button type="button" class="btn btn-default" data-dismiss="modal">Fechar</button>
                    </div>
                </div>

            </div>
        </div>

<script type="text/javascript">
    ;(function($) {
        $('#modalItensCupom').on('show.bs.modal', function() {
            var idata  = $("#data").val();
            var iloja  = $("#loja").val();
            var ipdv   = $("#pdv").val();
            var icupom = $("#cupom").val();

            $( '#rdata' ).text( idata );
            $( '#rloja' ).text( iloja );
            $( '#rpdv' ).text( ipdv );
            $( '#rcupom' ).text( icupom );
        });
    }(jQuery));
</script>