enter_information_v3.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    $DOB='';
  14   if (isset($_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');