enter_information.php

   1 <?PHP
   2 if (isset($_COOKIE['form_version'])){
   3   if ($_COOKIE['form_version'] == '2'){
   4    header('Location: enter_information_v2.php');
   5   }
   6   if ($_COOKIE['form_version'] == '3'){
   7     header('Location: enter_information_v2.php');
   8   }
   9 }
  10 if (empty($_COOKIE['signature_status'])){
  11    setcookie("signature_status", 'unverified');
  12 }
  13 if (isset($_POST['web_first_name'])){
  14   $email='';
  15   if (isset($_POST['email'])){
  16     if ($_POST['email'] != ''){
  17      $email = $_POST['email'];
  18      setcookie("email", $email);
  19     }
  20   }
  21    $DOB='';
  22   if (isset($_POST['DOB'])){
  23     if ($_POST['DOB'] != ''){
  24      $DOB = $_POST['DOB'];
  25      setcookie("pDOB", $DOB);
  26     }
  27   }
  28   $web_first_name='';
  29   if (isset($_POST['web_first_name'])){
  30     if ($_POST['web_first_name'] != ''){
  31      $web_first_name = $_POST['web_first_name'];
  32      setcookie("web_first_name", $web_first_name);
  33     }
  34   }
  35   $web_last_name='';
  36   if (isset($_POST['web_last_name'])){
  37     if ($_POST['web_last_name'] != ''){
  38      $web_last_name = $_POST['web_last_name'];
  39      setcookie("web_last_name", $web_last_name);
  40     }
  41   }
  42   if(isset($_POST['web_last_name']) && isset($_POST['web_first_name'])){
  43      setcookie("web_name", $web_first_name.' '.$web_last_name);
  44   }
  45   $web_house_number='';
  46   if (isset($_POST['web_house_number'])){
  47     if ($_POST['web_house_number'] != ''){
  48      $web_house_number = $_POST['web_house_number'];
  49      setcookie("web_house_number", $web_house_number);
  50     }
  51   }
  52   $web_zip_code='';
  53   if (isset($_POST['web_zip_code'])){
  54     if ($_POST['web_zip_code'] != ''){
  55      $web_zip_code = $_POST['web_zip_code'];
  56      setcookie("web_zip_code", $web_zip_code);
  57     }
  58   }
  59   $contact_phone='';
  60   if (isset($_POST['contact_phone'])){
  61     if ($_POST['contact_phone'] != ''){
  62      $contact_phone = $_POST['contact_phone'];
  63      setcookie("pPHONE", $contact_phone);
  64     }
  65   }
  66   header('Location: is_the_information_correct.php');
  67 }
  68 include_once('header.php');
  69 slack_general('Enter Information ('.$_COOKIE['invite'].')','md-petition');
  70 ?>
  71    <link id="bsdp-css" href="files/bootstrap-datepicker3.min.css" rel="stylesheet">
  72    <script src="files/bootstrap-datepicker.min.js"></script>
  73   <?PHP
  74  $qX = "select * from website_text where id = '2'";
  75  $rX = $petition->query($qX);
  76  $dX = mysqli_fetch_array($rX);
  77 ?>
  78 <script>document.title = "MEPS - Enter Information";</script>
  79 <form method='POST'>
  80
  81   <div class='row'>
  82     <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>
  83   </div>
  84
  85
  86   <div class='row'>
  87     <div class='col-sm-3' style='text-align:right;'><h2>E-Mail for Follow Up*</h2></div>
  88     <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>
  89     <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div>
  90   </div>
  91
  92   <div class='row'>
  93     <div class='col-sm-3' style='text-align:right;'><h2>First Name</h2></div>
  94     <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>
  95     <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div>
  96   </div>
  97
  98   <div class='row'>
  99      <div class='col-sm-3' style='text-align:right;'><h2>Last Name</h2></div>
 100      <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>
 101      <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div>
 102   </div>
 103
 104   <div class='row'>
 105      <div class='col-sm-3' style='text-align:right;'><h2>Date of Birth</h2></div>
 106      <div class='col-sm-6'>
 107             <div class="input-group date">
 108               <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('')">
 109             </div>
 110          <script>
 111                var $d = jQuery.noConflict();
 112                $d('.input-group.date').datepicker({
 113                    format: "mm/dd/yyyy",
 114                    clearBtn: true
 115                });
 116          </script>
 117        </div>
 118      <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></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, and will only be used with the petitioners to reach you. It will never be sold.</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');