Commit | Line | Data |
---|---|---|
3ed46210 PM |
1 | <?PHP |
2 | if (empty($_COOKIE['signature_status'])){ | |
3 | setcookie("signature_status", 'unverified'); | |
4 | } | |
5 | if (isset($_POST['web_first_name'])){ | |
6 | $email=''; | |
7 | if (isset($_POST['email'])){ | |
8 | if ($_POST['email'] != ''){ | |
9 | $email = $_POST['email']; | |
10 | setcookie("email", $email); | |
11 | } | |
12 | } | |
13 | $DOB=''; | |
7d2bb73a PM |
14 | // old DOB form |
15 | if (isset($_POST['DOB'])){ | |
3ed46210 PM |
16 | if ($_POST['DOB'] != ''){ |
17 | $DOB = $_POST['DOB']; | |
18 | setcookie("pDOB", $DOB); | |
19 | } | |
20 | } | |
7d2bb73a PM |
21 | // new DOB form |
22 | if (isset($_POST['web_dob_day'])){ | |
23 | if ($_POST['web_dob_day'] != ''){ | |
be13ef2a | 24 | $DOB = intval($_POST['web_dob_year']).'-'.intval($_POST['web_dob_month']).'-'.intval($_POST['web_dob_day']); |
7d2bb73a PM |
25 | setcookie("pDOB", $DOB); |
26 | setcookie("web_dob_month", $_POST['web_dob_month']); | |
27 | setcookie("web_dob_year", $_POST['web_dob_year']); | |
28 | setcookie("web_dob_day", $_POST['web_dob_day']); | |
29 | } | |
30 | } | |
3ed46210 PM |
31 | $web_first_name=''; |
32 | if (isset($_POST['web_first_name'])){ | |
33 | if ($_POST['web_first_name'] != ''){ | |
34 | $web_first_name = $_POST['web_first_name']; | |
35 | setcookie("web_first_name", $web_first_name); | |
36 | } | |
37 | } | |
38 | $web_last_name=''; | |
39 | if (isset($_POST['web_last_name'])){ | |
40 | if ($_POST['web_last_name'] != ''){ | |
41 | $web_last_name = $_POST['web_last_name']; | |
42 | setcookie("web_last_name", $web_last_name); | |
43 | } | |
44 | } | |
45 | if(isset($_POST['web_last_name']) && isset($_POST['web_first_name'])){ | |
46 | setcookie("web_name", $web_first_name.' '.$web_last_name); | |
47 | } | |
48 | $web_house_number=''; | |
49 | if (isset($_POST['web_house_number'])){ | |
50 | if ($_POST['web_house_number'] != ''){ | |
be13ef2a | 51 | $web_house_number = intval($_POST['web_house_number']); |
3ed46210 PM |
52 | setcookie("web_house_number", $web_house_number); |
53 | } | |
54 | } | |
55 | $web_zip_code=''; | |
56 | if (isset($_POST['web_zip_code'])){ | |
57 | if ($_POST['web_zip_code'] != ''){ | |
be13ef2a | 58 | $web_zip_code = substr(intval($_POST['web_zip_code']),0,5); |
3ed46210 PM |
59 | setcookie("web_zip_code", $web_zip_code); |
60 | } | |
61 | } | |
62 | $contact_phone=''; | |
63 | if (isset($_POST['contact_phone'])){ | |
64 | if ($_POST['contact_phone'] != ''){ | |
65 | $contact_phone = $_POST['contact_phone']; | |
66 | setcookie("pPHONE", $contact_phone); | |
67 | } | |
68 | } | |
69 | header('Location: is_the_information_correct.php'); | |
70 | } | |
71 | include_once('header.php'); | |
72 | slack_general('Enter Information ('.$_COOKIE['invite'].')','md-petition'); | |
73 | ?> | |
74 | <link id="bsdp-css" href="files/bootstrap-datepicker3.min.css" rel="stylesheet"> | |
75 | <script src="files/bootstrap-datepicker.min.js"></script> | |
76 | <?PHP | |
77 | $qX = "select * from website_text where id = '2'"; | |
78 | $rX = $petition->query($qX); | |
79 | $dX = mysqli_fetch_array($rX); | |
80 | ?> | |
81 | <script>document.title = "MEPS - Enter Information";</script> | |
82 | <form method='POST'> | |
83 | ||
84 | <div class='row'> | |
85 | <div class='col-sm-10' style='text-align:center;'><h1><?PHP echo $dX['text_title'];?></h1><h2 style="margin:10px; padding:10px; background-color:lightyellow;"><?PHP echo $dX['text_block'];?></h2></div> | |
86 | </div> | |
87 | ||
88 | ||
89 | <div class='row'> | |
90 | <div class='col-sm-3' style='text-align:right;'><h2>E-Mail for Follow Up*</h2></div> | |
91 | <div class='col-sm-6' style='text-align:left;'><input class="form-control input-lg" name='email' oninvalid="this.setCustomValidity('Please enter an email address for follow up')" oninput="this.setCustomValidity('')" ></div> | |
92 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> | |
93 | </div> | |
94 | ||
95 | <div class='row'> | |
96 | <div class='col-sm-3' style='text-align:right;'><h2>First Name</h2></div> | |
97 | <div class='col-sm-6' style='text-align:left;'><input class="form-control input-lg" name='web_first_name' required oninvalid="this.setCustomValidity('Please enter only your first name')" oninput="this.setCustomValidity('')" ></div> | |
98 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> | |
99 | </div> | |
100 | ||
101 | <div class='row'> | |
102 | <div class='col-sm-3' style='text-align:right;'><h2>Last Name</h2></div> | |
103 | <div class='col-sm-6' style='text-align:left;'><input class="form-control input-lg" name='web_last_name' required oninvalid="this.setCustomValidity('Please enter only your last name')" oninput="this.setCustomValidity('')"></div> | |
104 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> | |
105 | </div> | |
3ed46210 PM |
106 | <div class='row'> |
107 | <div class='col-sm-3' style='text-align:right;'><h2>Date of Birth</h2></div> | |
7d2bb73a | 108 | <div class='col-sm-2' style='text-align:left;'><input type='number' class="form-control input-lg" name='web_dob_month' required oninvalid="this.setCustomValidity('Please enter the month you were born.')" oninput="this.setCustomValidity('')"></div> |
be13ef2a | 109 | <div class='col-sm-2' style='text-align:left;'><input type='number' class="form-control input-lg" name='web_dob_day' required oninvalid="this.setCustomValidity('Please the day you were born.')" oninput="this.setCustomValidity('')"></div> |
7d2bb73a | 110 | <div class='col-sm-2' style='text-align:left;'><input type='number' class="form-control input-lg" name='web_dob_year' required oninvalid="this.setCustomValidity('Please enter the year you were born.')" oninput="this.setCustomValidity('')"></div> |
3ed46210 PM |
111 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> |
112 | </div> | |
113 | <div class='row'> | |
114 | <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>Date of Birth Format</h3></div> | |
be13ef2a PM |
115 | <div class='col-sm-2' style='text-align:left; background-color:lightyellow;'><h3>MM</h3></div> |
116 | <div class='col-sm-2' style='text-align:left; background-color:lightyellow;'><h3>DD</h3></div> | |
117 | <div class='col-sm-2' style='text-align:left; background-color:lightyellow;'><h3>YYYY</h3></div> | |
3ed46210 PM |
118 | <div class='col-sm-1' style='text-align:center;'></div> |
119 | </div> | |
120 | <div class='row'> | |
121 | <div class='col-sm-3' style='text-align:right;'><h2>Phone Number**</h2></div> | |
122 | <div class='col-sm-6' style='text-align:left;'><input class="form-control input-lg" id="contact_phone" name="contact_phone" pattern="[0-9]{3}-[0-9]{3}-[0-9]{4}" required oninvalid="this.setCustomValidity('please enter your phone number with area code with hyphens like 1 2 3 dash 4 5 6 dash 7 8 9 0')" oninput="this.setCustomValidity('')"></div> | |
123 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</div> | |
124 | </div> | |
125 | <div class='row'> | |
126 | <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>Phone Format</h3></div> | |
127 | <div class='col-sm-6' style='text-align:left; background-color:lightyellow;'><h3>443-123-4567</h3></div> | |
128 | <div class='col-sm-1' style='text-align:center;'></div> | |
129 | </div> | |
130 | <div class='row'> | |
131 | <div class='col-sm-3' style='text-align:right;'><h2>Building Number</h2></div> | |
132 | <div class='col-sm-6' style='text-align:left;'><input class="form-control input-lg" name='web_house_number' type='number' required oninvalid="this.setCustomValidity('Please enter your house number without street name')" oninput="this.setCustomValidity('')"> </div> | |
133 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> | |
134 | </div> | |
135 | <div class='row'> | |
136 | <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>House: 321 Here St.</h3></div> | |
137 | <div class='col-sm-6' style='text-align:left; background-color:lightyellow;'><h3>Use: 321</h3></div> | |
138 | <div class='col-sm-1' style='text-align:center;'></div> | |
139 | </div> | |
140 | <div class='row'> | |
141 | <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>Apartment: 21 Here St. Apt 1323</h3></div> | |
142 | <div class='col-sm-6' style='text-align:left; background-color:lightyellow;'><h3>Use: 21</h3></div> | |
143 | <div class='col-sm-1' style='text-align:center;'></div> | |
144 | </div> | |
145 | <div class='row'> | |
146 | <div class='col-sm-3' style='text-align:right;'><h2>ZIP Code</h2></div> | |
147 | <div class='col-sm-6' style='text-align:left;'><input class="form-control input-lg" name='web_zip_code' type='number' required oninvalid="this.setCustomValidity('Please enter your five digit zip code')" oninput="this.setCustomValidity('')"> </div> | |
148 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> | |
149 | </div> | |
150 | <div class='row'> | |
151 | <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>ZIP Code Format</h3></div> | |
152 | <div class='col-sm-6' style='text-align:left; background-color:lightyellow;'><h3>55555</h3></div> | |
153 | <div class='col-sm-1' style='text-align:center;'></div> | |
154 | </div> | |
155 | <div class='row'> | |
156 | <div class='col-sm-10' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block"><img alt='Click Here to Continue' class='click_me' src="files/click_here.gif">Next</button></div> | |
157 | </div> | |
158 | <div class='row'> | |
159 | <div class='col-sm-10' style='text-align:center;'><button type="reset" class="btn btn-warning btn-lg btn-block not_me">Clear</button></div> | |
160 | </div> | |
161 | <div class='row'> | |
be13ef2a | 162 | <div class='col-sm-10' style='text-align:center;'>* E-Mail is not required, it will only be used internally to reach you. It will never sold or given out.</div> |
3ed46210 PM |
163 | </div> |
164 | <div class='row'> | |
165 | <div class='col-sm-10' style='text-align:center;'>** PHONE NUMBER IS REQUIRED BY STATE OF MARYLAND. WE WILL NEVER USE YOUR PHONE NUMBER - NEVER CALL - NEVER FOR TEXT MESSAGES.</div> | |
166 | </div> | |
167 | </form> | |
168 | ||
169 | <?PHP include_once('footer.php'); |