2 if (empty($_COOKIE['signature_status'])){
3 setcookie("signature_status", 'unverified');
5 if (isset($_POST['web_first_name'])){
7 if (isset($_POST['DOB'])){
8 if ($_POST['DOB'] != ''){
10 setcookie("pDOB", $DOB);
14 if (isset($_POST['web_first_name'])){
15 if ($_POST['web_first_name'] != ''){
16 $web_first_name = $_POST['web_first_name'];
17 setcookie("web_first_name", $web_first_name);
21 if (isset($_POST['web_last_name'])){
22 if ($_POST['web_last_name'] != ''){
23 $web_last_name = $_POST['web_last_name'];
24 setcookie("web_last_name", $web_last_name);
27 if(isset($_POST['web_last_name']) && isset($_POST['web_first_name'])){
28 setcookie("web_name", $web_first_name.' '.$web_last_name);
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", $web_house_number);
38 if (isset($_POST['web_zip_code'])){
39 if ($_POST['web_zip_code'] != ''){
40 $web_zip_code = $_POST['web_zip_code'];
41 setcookie("web_zip_code", $web_zip_code);
45 if (isset($_POST['contact_phone'])){
46 if ($_POST['contact_phone'] != ''){
47 $contact_phone = $_POST['contact_phone'];
48 setcookie("pPHONE", $contact_phone);
51 header('Location: is_the_information_correct.php');
53 include_once('header.php');
54 slack_general('Enter Information ('.$_COOKIE['invite'].')','md-petition');
56 <link id
="bsdp-css" href
="files/bootstrap-datepicker3.min.css" rel
="stylesheet">
57 <script src
="files/bootstrap-datepicker.min.js"></script
>
59 $qX = "select * from website_text where id = '2'";
60 $rX = $petition->query($qX);
61 $dX = mysqli_fetch_array($rX);
63 <script
>document
.title
= "MEPS - Enter Information";</script
>
67 <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
>
73 <div
class='col-sm-3' style
='text-align:right;'><h2
>First Name
</h2
></div
>
74 <div
class='col-sm-6' style
='text-align:left;'><input
class="form-control input-lg" name
='web_first_name' required
></div
>
75 <div
class='col-sm-1' style
='text-align:center;'><button type
="submit" class="btn btn-success btn-lg btn-block">↴
</button
></div
>
80 <div
class='col-sm-3' style
='text-align:right;'><h2
>Last Name
</h2
></div
>
81 <div
class='col-sm-6' style
='text-align:left;'><input
class="form-control input-lg" name
='web_last_name' required
></div
>
82 <div
class='col-sm-1' style
='text-align:center;'><button type
="submit" class="btn btn-success btn-lg btn-block">↴
</button
></div
>
86 <div
class='col-sm-3' style
='text-align:right;'><h2
>Date of Birth
</h2
></div
>
87 <div
class='col-sm-6'>
88 <div
class="input-group date">
89 <span
class="input-group-addon"><i
class="glyphicon glyphicon-th"></i
></span
><input name
='DOB' type
="text" class="form-control input-lg" required
>
92 var $d = jQuery
.noConflict();
93 $d('.input-group.date').datepicker({
99 <div
class='col-sm-1' style
='text-align:center;'><button type
="submit" class="btn btn-success btn-lg btn-block">↴
</button
></div
>
102 <div
class='col-sm-3' style
='text-align:right;'><h2
>Phone Number
</h2
></div
>
103 <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
></div
>
104 <div
class='col-sm-1' style
='text-align:center;'><button type
="submit" class="btn btn-success btn-lg btn-block">↴
</div
>
107 <div
class='col-sm-3' style
='text-align:right; background-color:lightyellow;'><h3
>Phone Format
</h3
></div
>
108 <div
class='col-sm-6' style
='text-align:left; background-color:lightyellow;'><h3
>443-123-4567</h3
></div
>
109 <div
class='col-sm-1' style
='text-align:center;'><button type
="submit" class="btn btn-success btn-lg btn-block">↴
</button
></div
>
112 <div
class='col-sm-3' style
='text-align:right;'><h2
>House Number
</h2
></div
>
113 <div
class='col-sm-6' style
='text-align:left;'><input
class="form-control input-lg" name
='web_house_number' type
='number' required
> </div
>
114 <div
class='col-sm-1' style
='text-align:center;'><button type
="submit" class="btn btn-success btn-lg btn-block">↴
</button
></div
>
117 <div
class='col-sm-3' style
='text-align:right; background-color:lightyellow;'><h3
>House Format
</h3
></div
>
118 <div
class='col-sm-6' style
='text-align:left; background-color:lightyellow;'><h3
>321</h3
></div
>
119 <div
class='col-sm-1' style
='text-align:center;'><button type
="submit" class="btn btn-success btn-lg btn-block">↴
</button
></div
>
122 <div
class='col-sm-3' style
='text-align:right;'><h2
>ZIP Code
</h2
></div
>
123 <div
class='col-sm-6' style
='text-align:left;'><input
class="form-control input-lg" name
='web_zip_code' type
='number' required
> </div
>
124 <div
class='col-sm-1' style
='text-align:center;'><button type
="submit" class="btn btn-success btn-lg btn-block">↴
</button
></div
>
127 <div
class='col-sm-3' style
='text-align:right; background-color:lightyellow;'><h3
>ZIP Code Format
</h3
></div
>
128 <div
class='col-sm-6' style
='text-align:left; background-color:lightyellow;'><h3
>55555</h3
></div
>
129 <div
class='col-sm-1' style
='text-align:center;'><button type
="submit" class="btn btn-success btn-lg btn-block">↴
</button
></div
>
132 <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
>
135 <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
>
139 <?PHP
include_once('footer.php');