enter_information_v2.php

   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    $DOB='';
  14   // old DOB form
  15    if (isset($_POST['DOB'])){
  16     if ($_POST['DOB'] != ''){
  17      $DOB = $_POST['DOB'];
  18      setcookie("pDOB", $DOB);
  19     }
  20   }
  21   // new DOB form
  22    if (isset($_POST['web_dob_day'])){
  23     if ($_POST['web_dob_day'] != ''){
  24        $DOB = intval($_POST['web_dob_year']).'-'.intval($_POST['web_dob_month']).'-'.intval($_POST['web_dob_day']);
  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   }
  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'] != ''){
  51      $web_house_number = intval($_POST['web_house_number']);
  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'] != ''){
  58      $web_zip_code = substr(intval($_POST['web_zip_code']),0,5);
  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>
 106   <div class='row'>
 107      <div class='col-sm-3' style='text-align:right;'><h2>Date of Birth</h2></div>
 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>
 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>
 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>
 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>
 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>
 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'>
 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>
 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');