Update abuse.php

[clinton/MarylandElectronicPetitionSignature.git] / enter_information.php

diff --git a/enter_information.php b/enter_information.php
index 4aa6bd1..6d1be7b 100644 (file)
--- a/enter_information.php
+++ b/enter_information.php
@@ -51,54 +51,89 @@ if (isset($_POST['web_first_name'])){
   header('Location: is_the_information_correct.php');
 }
 include_once('header.php');
-slack_general('Entering Information','md-petition');
+slack_general('Enter Information ('.$_COOKIE['invite'].')','md-petition');
+?>
+   <link id="bsdp-css" href="files/bootstrap-datepicker3.min.css" rel="stylesheet">
+   <script src="files/bootstrap-datepicker.min.js"></script>
+  <?PHP
  $qX = "select * from website_text where id = '2'";
  $rX = $petition->query($qX);
  $dX = mysqli_fetch_array($rX);
 ?>
 <script>document.title = "MEPS - Enter Information";</script>
 <form method='POST'>
-  
+    
   <div class='row'>
-    <div class='col-sm-12' 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>
+    <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>
   </div>
    
+   
+     
   <div class='row'>
-    <div class='col-sm-6' style='height:50px; text-align:center;'><h2>First Name</h2></div>
-    <div class='col-sm-6' style='height:50px; text-align:center;'><h2>Last Name</h2></div>
-  </div>
+    <div class='col-sm-3' style='text-align:right;'><h2>First Name</h2></div>
+    <div class='col-sm-6' style='text-align:left;'><input class="form-control input-lg" name='web_first_name' required></div>
+    <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div>
+
+  </div>  
    
-  <div class='row'> 
-    <div class='col-sm-6' style='height:50px; text-align:center;'><input name='web_first_name'></div>
-    <div class='col-sm-6' style='height:50px; text-align:center;'><input name='web_last_name'></div> 
+  <div class='row'>
+     <div class='col-sm-3' style='text-align:right;'><h2>Last Name</h2></div>
+     <div class='col-sm-6' style='text-align:left;'><input class="form-control input-lg" name='web_last_name' required></div>
+     <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div>
   </div> 
    
   <div class='row'>
-     <div class='col-sm-6' style='height:50px; text-align:center;'><h2>Date of Birth</h2></div>
-     <div class='col-sm-6' style='height:50px; text-align:center;'><h2>Phone Number</h2></div>
+     <div class='col-sm-3' style='text-align:right;'><h2>Date of Birth</h2></div>
+     <div class='col-sm-6'>
+            <div class="input-group date">
+              <span class="input-group-addon"><i class="glyphicon glyphicon-th"></i></span><input name='DOB' type="text" class="form-control input-lg" required>
+            </div>
+         <script>
+               var $d = jQuery.noConflict();
+               $d('.input-group.date').datepicker({
+                   format: "mm/dd/yyyy",
+                   clearBtn: true
+               });
+         </script>
+       </div>
+     <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div>
   </div> 
-   
-  <div class='row'> 
-    <div class='col-sm-6' style='height:50px; text-align:center;'><input name='DOB' type="date"></div>
-    <div class='col-sm-6' style='height:50px; text-align:center;'><input name='contact_phone' type='tel'> </div>
+  <div class='row'>
+      <div class='col-sm-3' style='text-align:right;'><h2>Phone Number</h2></div>
+      <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>
+      <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</div>
   </div>
-   
   <div class='row'>
-    <div class='col-sm-6' style='height:50px; text-align:center;'><h2>House Number</h2></div>
-    <div class='col-sm-6' style='height:50px; text-align:center;'><h2>ZIP Code</h2></div>
+     <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>Phone Format</h3></div>
+     <div class='col-sm-6' style='text-align:left; background-color:lightyellow;'><h3>443-123-4567</h3></div>
+     <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div>
   </div>
-   
   <div class='row'>
-    <div class='col-sm-6' style='height:50px; text-align:center;'><input name='web_house_number' type='number'> </div>
-    <div class='col-sm-6' style='height:50px; text-align:center;'><input name='web_zip_code' type='number'> </div>
+    <div class='col-sm-3' style='text-align:right;'><h2>House Number</h2></div>
+    <div class='col-sm-6' style='text-align:left;'><input class="form-control input-lg" name='web_house_number' type='number' required> </div>
+    <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div>
+  </div>  
+  <div class='row'>
+     <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>House Format</h3></div>
+     <div class='col-sm-6' style='text-align:left; background-color:lightyellow;'><h3>321</h3></div>
+     <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div>
+  </div>     
+  <div class='row'>
+     <div class='col-sm-3' style='text-align:right;'><h2>ZIP Code</h2></div>
+     <div class='col-sm-6' style='text-align:left;'><input class="form-control input-lg" name='web_zip_code' type='number' required> </div>
+     <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div>
   </div>
-   
-   
   <div class='row'>
-    <div class='col-sm-6' style='height:50px; text-align:center;'><button type="reset" class="btn btn-warning btn-lg btn-block">Clear</button></div>
-    <div class='col-sm-6' style='height:50px; text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">Next</button></div>
+     <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>ZIP Code Format</h3></div>
+     <div class='col-sm-6' style='text-align:left; background-color:lightyellow;'><h3>55555</h3></div>
+     <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div>
+  </div> 
+  <div class='row'>
+     <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>
+  </div>
+  <div class='row'>
+     <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>
   </div>
-   
 </form>
 
 <?PHP include_once('footer.php');