enter_information.php

   1 <?PHP
   2 if (empty($_COOKIE['signature_status'])){
   3    setcookie("signature_status", 'unverified');
   4 }
   5 if (isset($_POST['web_first_name'])){
   6   $DOB='';
   7   if (isset($_POST['DOB'])){
   8     if ($_POST['DOB'] != ''){
   9      $DOB = $_POST['DOB'];
  10      setcookie("pDOB", $DOB);
  11     }
  12   }
  13   $web_first_name='';
  14   if (isset($_POST['web_first_name'])){
  15     if ($_POST['web_first_name'] != ''){
  16      $web_first_name = $_POST['web_first_name'];
  17      setcookie("web_first_name", $web_first_name);
  18     }
  19   }
  20   $web_last_name='';
  21   if (isset($_POST['web_last_name'])){
  22     if ($_POST['web_last_name'] != ''){
  23      $web_last_name = $_POST['web_last_name'];
  24      setcookie("web_last_name", $web_last_name);
  25     }
  26   }
  27   if(isset($_POST['web_last_name']) && isset($_POST['web_first_name'])){
  28      setcookie("web_name", $web_first_name.' '.$web_last_name);
  29   }
  30   $web_house_number='';
  31   if (isset($_POST['web_house_number'])){
  32     if ($_POST['web_house_number'] != ''){
  33      $web_house_number = $_POST['web_house_number'];
  34      setcookie("web_house_number", $web_house_number);
  35     }
  36   }
  37   $web_zip_code='';
  38   if (isset($_POST['web_zip_code'])){
  39     if ($_POST['web_zip_code'] != ''){
  40      $web_zip_code = $_POST['web_zip_code'];
  41      setcookie("web_zip_code", $web_zip_code);
  42     }
  43   }
  44   $contact_phone='';
  45   if (isset($_POST['contact_phone'])){
  46     if ($_POST['contact_phone'] != ''){
  47      $contact_phone = $_POST['contact_phone'];
  48      setcookie("pPHONE", $contact_phone);
  49     }
  50   }
  51   header('Location: is_the_information_correct.php');
  52 }
  53 include_once('header.php');
  54 slack_general('Enter Information ('.$_COOKIE['invite'].')','md-petition');
  55 ?>
  56    <link id="bsdp-css" href="files/bootstrap-datepicker3.min.css" rel="stylesheet">
  57    <script src="files/bootstrap-datepicker.min.js"></script>
  58   <?PHP
  59  $qX = "select * from website_text where id = '2'";
  60  $rX = $petition->query($qX);
  61  $dX = mysqli_fetch_array($rX);
  62 ?>
  63 <script>document.title = "MEPS - Enter Information";</script>
  64 <form method='POST'>
  65     <div class='row'>
  66      <div class='col-sm-10' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block"><img class='click_me' src="files/click_here.gif">Next</button></div>
  67   </div>
  68   <div class='row'>
  69     <div class='col-sm-10' style='text-align:center;'><h1><?PHP echo $dX['text_title'];?></h1><h2 style="margin:25px; padding25px; background-color:lightyellow;"><?PHP echo $dX['text_block'];?></h2></div>
  70   </div>
  71
  72
  73   <div class='row'>
  74     <div class='col-sm-3' style='text-align:right;'><h2>First Name</h2></div>
  75     <div class='col-sm-7' style='text-align:left;'><input class="form-control input-lg" name='web_first_name' required></div>
  76   </div>
  77
  78   <div class='row'>
  79      <div class='col-sm-3' style='text-align:right;'><h2>Last Name</h2></div>
  80      <div class='col-sm-7' style='text-align:left;'><input class="form-control input-lg" name='web_last_name' required></div>
  81   </div>
  82
  83   <div class='row'>
  84      <div class='col-sm-3' style='text-align:right;'><h2>Date of Birth</h2></div>
  85      <div class='col-sm-7'>
  86             <div class="input-group date">
  87               <span class="input-group-addon"><i class="glyphicon glyphicon-th"></i></span><input name='DOB' type="text" class="form-control input-lg" required>
  88             </div>
  89          <script>
  90                var $d = jQuery.noConflict();
  91                $d('.input-group.date').datepicker({
  92                    format: "mm/dd/yyyy",
  93                    clearBtn: true
  94                });
  95          </script>
  96        </div>
  97    </div>
  98
  99   <div class='row'>
 100       <div class='col-sm-3' style='text-align:right;'><h2>Phone Number</h2></div>
 101       <div class='col-sm-7' 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></div>
 102   </div>
 103   <div class='row'>
 104       <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>Phone Format</h3></div>
 105      <div class='col-sm-7' style='text-align:left; background-color:lightyellow;'><h3>443-123-4567</h3></div>
 106   </div>
 107
 108   <div class='row'>
 109     <div class='col-sm-3' style='text-align:right;'><h2>House Number</h2></div>
 110     <div class='col-sm-7' style='text-align:left;'><input class="form-control input-lg" name='web_house_number' type='number' required> </div>
 111  </div>
 112
 113   <div class='row'>
 114       <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>House Format</h3></div>
 115      <div class='col-sm-7' style='text-align:left; background-color:lightyellow;'><h3>321</h3></div>
 116   </div>
 117
 118   <div class='row'>
 119      <div class='col-sm-3' style='text-align:right;'><h2>ZIP Code</h2></div>
 120      <div class='col-sm-7' style='text-align:left;'><input class="form-control input-lg" name='web_zip_code' type='number' required> </div>
 121   </div>
 122
 123   <div class='row'>
 124       <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>ZIP Code Format</h3></div>
 125      <div class='col-sm-7' style='text-align:left; background-color:lightyellow;'><h3>55555</h3></div>
 126   </div>
 127
 128
 129    <div class='row'>
 130     <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>
 131    </div>
 132 </form>
 133
 134 <?PHP include_once('footer.php');