| 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 | $DOB=''; |
| 14 | if (isset($_POST['DOB'])){ |
| 15 | if ($_POST['DOB'] != ''){ |
| 16 | $DOB = $_POST['DOB']; |
| 17 | setcookie("pDOB", $DOB); |
| 18 | } |
| 19 | } |
| 20 | $web_first_name=''; |
| 21 | if (isset($_POST['web_first_name'])){ |
| 22 | if ($_POST['web_first_name'] != ''){ |
| 23 | $web_first_name = $_POST['web_first_name']; |
| 24 | setcookie("web_first_name", $web_first_name); |
| 25 | } |
| 26 | } |
| 27 | $web_last_name=''; |
| 28 | if (isset($_POST['web_last_name'])){ |
| 29 | if ($_POST['web_last_name'] != ''){ |
| 30 | $web_last_name = $_POST['web_last_name']; |
| 31 | setcookie("web_last_name", $web_last_name); |
| 32 | } |
| 33 | } |
| 34 | if(isset($_POST['web_last_name']) && isset($_POST['web_first_name'])){ |
| 35 | setcookie("web_name", $web_first_name.' '.$web_last_name); |
| 36 | } |
| 37 | $web_house_number=''; |
| 38 | if (isset($_POST['web_house_number'])){ |
| 39 | if ($_POST['web_house_number'] != ''){ |
| 40 | $web_house_number = $_POST['web_house_number']; |
| 41 | setcookie("web_house_number", $web_house_number); |
| 42 | } |
| 43 | } |
| 44 | $web_zip_code=''; |
| 45 | if (isset($_POST['web_zip_code'])){ |
| 46 | if ($_POST['web_zip_code'] != ''){ |
| 47 | $web_zip_code = $_POST['web_zip_code']; |
| 48 | setcookie("web_zip_code", $web_zip_code); |
| 49 | } |
| 50 | } |
| 51 | $contact_phone=''; |
| 52 | if (isset($_POST['contact_phone'])){ |
| 53 | if ($_POST['contact_phone'] != ''){ |
| 54 | $contact_phone = $_POST['contact_phone']; |
| 55 | setcookie("pPHONE", $contact_phone); |
| 56 | } |
| 57 | } |
| 58 | header('Location: is_the_information_correct.php'); |
| 59 | } |
| 60 | include_once('header.php'); |
| 61 | slack_general('Enter Information ('.$_COOKIE['invite'].')','md-petition'); |
| 62 | ?> |
| 63 | <link id="bsdp-css" href="files/bootstrap-datepicker3.min.css" rel="stylesheet"> |
| 64 | <script src="files/bootstrap-datepicker.min.js"></script> |
| 65 | <?PHP |
| 66 | $qX = "select * from website_text where id = '2'"; |
| 67 | $rX = $petition->query($qX); |
| 68 | $dX = mysqli_fetch_array($rX); |
| 69 | ?> |
| 70 | <script>document.title = "MEPS - Enter Information";</script> |
| 71 | <form method='POST'> |
| 72 | |
| 73 | <div class='row'> |
| 74 | <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> |
| 75 | </div> |
| 76 | |
| 77 | |
| 78 | <div class='row'> |
| 79 | <div class='col-sm-3' style='text-align:right;'><h2>E-Mail for Follow Up*</h2></div> |
| 80 | <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> |
| 81 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> |
| 82 | </div> |
| 83 | |
| 84 | <div class='row'> |
| 85 | <div class='col-sm-3' style='text-align:right;'><h2>First Name</h2></div> |
| 86 | <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> |
| 87 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> |
| 88 | </div> |
| 89 | |
| 90 | <div class='row'> |
| 91 | <div class='col-sm-3' style='text-align:right;'><h2>Last Name</h2></div> |
| 92 | <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> |
| 93 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> |
| 94 | </div> |
| 95 | |
| 96 | <div class='row'> |
| 97 | <div class='col-sm-3' style='text-align:right;'><h2>Date of Birth</h2></div> |
| 98 | <div class='col-sm-6'> |
| 99 | <div class="input-group date"> |
| 100 | <span class="input-group-addon"><i class="glyphicon glyphicon-th"></i></span><input name='DOB' type="text" class="form-control input-lg" required oninvalid="this.setCustomValidity('Please enter your date of birth in the format month month slash day day slash year year year year')" oninput="this.setCustomValidity('')"> |
| 101 | </div> |
| 102 | <script> |
| 103 | var $d = jQuery.noConflict(); |
| 104 | $d('.input-group.date').datepicker({ |
| 105 | format: "mm/dd/yyyy", |
| 106 | clearBtn: true |
| 107 | }); |
| 108 | </script> |
| 109 | </div> |
| 110 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> |
| 111 | </div> |
| 112 | <div class='row'> |
| 113 | <div class='col-sm-3' style='text-align:right;'><h2>Phone Number**</h2></div> |
| 114 | <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> |
| 115 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</div> |
| 116 | </div> |
| 117 | <div class='row'> |
| 118 | <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>Phone Format</h3></div> |
| 119 | <div class='col-sm-6' style='text-align:left; background-color:lightyellow;'><h3>443-123-4567</h3></div> |
| 120 | <div class='col-sm-1' style='text-align:center;'></div> |
| 121 | </div> |
| 122 | <div class='row'> |
| 123 | <div class='col-sm-3' style='text-align:right;'><h2>Building Number</h2></div> |
| 124 | <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> |
| 125 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> |
| 126 | </div> |
| 127 | <div class='row'> |
| 128 | <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>House: 321 Here St.</h3></div> |
| 129 | <div class='col-sm-6' style='text-align:left; background-color:lightyellow;'><h3>Use: 321</h3></div> |
| 130 | <div class='col-sm-1' style='text-align:center;'></div> |
| 131 | </div> |
| 132 | <div class='row'> |
| 133 | <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>Apartment: 21 Here St. Apt 1323</h3></div> |
| 134 | <div class='col-sm-6' style='text-align:left; background-color:lightyellow;'><h3>Use: 21</h3></div> |
| 135 | <div class='col-sm-1' style='text-align:center;'></div> |
| 136 | </div> |
| 137 | <div class='row'> |
| 138 | <div class='col-sm-3' style='text-align:right;'><h2>ZIP Code</h2></div> |
| 139 | <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> |
| 140 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> |
| 141 | </div> |
| 142 | <div class='row'> |
| 143 | <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>ZIP Code Format</h3></div> |
| 144 | <div class='col-sm-6' style='text-align:left; background-color:lightyellow;'><h3>55555</h3></div> |
| 145 | <div class='col-sm-1' style='text-align:center;'></div> |
| 146 | </div> |
| 147 | <div class='row'> |
| 148 | <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> |
| 149 | </div> |
| 150 | <div class='row'> |
| 151 | <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> |
| 152 | </div> |
| 153 | <div class='row'> |
| 154 | <div class='col-sm-10' style='text-align:center;'>* E-Mail is not required, and will only be used with the petitioners to reach you. It will never be sold.</div> |
| 155 | </div> |
| 156 | <div class='row'> |
| 157 | <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> |
| 158 | </div> |
| 159 | </form> |
| 160 | |
| 161 | <?PHP include_once('footer.php'); |