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('Entering Information','md-petition');
  55  $qX = "select * from website_text where id = '2'";
  56  $rX = $petition->query($qX);
  57  $dX = mysqli_fetch_array($rX);
  58 ?>
  59 <script>document.title = "MEPS - Enter Information";</script>
  60 <form method='POST'>
  61
  62   <div class='row'>
  63     <div class='col-sm-8' 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>
  64   </div>
  65
  66
  67   <div class='row'>
  68     <div class='col-sm-3' style='text-align:right;'><h2>First Name</h2></div>
  69     <div class='col-sm-5' style='text-align:left;'><input class="form-control input-lg" name='web_first_name'></div>
  70   </div>
  71
  72   <div class='row'>
  73      <div class='col-sm-3' style='text-align:right;'><h2>Last Name</h2></div>
  74      <div class='col-sm-5' style='text-align:left;'><input class="form-control input-lg" name='web_last_name'></div>
  75   </div>
  76
  77   <div class='row'>
  78      <div class='col-sm-3' style='text-align:right;'><h2>Date of Birth</h2></div>
  79      <div class='col-sm-5'>
  80             <div class="input-group date">
  81               <span class="input-group-addon"><i class="glyphicon glyphicon-th"></i></span><input name='DOB' type="text" class="form-control">
  82             </div>
  83          <script>
  84                var $d = jQuery.noConflict();
  85                $d('.input-group.date').datepicker({
  86                    format: "mm/dd/yyyy",
  87                    clearBtn: true
  88                });
  89          </script>
  90        </div>
  91    </div>
  92
  93    <div class='row'>
  94       <div class='col-sm-3' style='text-align:right;'><h2>Phone Number</h2></div>
  95       <div class='col-sm-5' style='text-align:left;'><input class="form-control input-lg" name='contact_phone' type='tel'> </div>
  96   </div>
  97
  98   <div class='row'>
  99     <div class='col-sm-3' style='text-align:right;'><h2>House Number</h2></div>
 100     <div class='col-sm-5' style='text-align:left;'><input class="form-control input-lg" name='web_house_number' type='number'> </div>
 101  </div>
 102
 103   <div class='row'>
 104      <div class='col-sm-3' style='text-align:right;'><h2>ZIP Code</h2></div>
 105      <div class='col-sm-5' style='text-align:left;'><input class="form-control input-lg" name='web_zip_code' type='number'> </div>
 106   </div>
 107
 108
 109   <div class='row'>
 110     <div class='col-sm-4' style='text-align:center;'><button type="reset" class="btn btn-warning btn-lg btn-block">Clear</button></div>
 111     <div class='col-sm-4' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">Next</button></div>
 112   </div>
 113
 114 </form>
 115
 116 <?PHP include_once('footer.php');