setcookie("signature_status", 'unverified');
}
if (isset($_POST['web_first_name'])){
- $DOB='';
+ $email='';
+ if (isset($_POST['email'])){
+ if ($_POST['email'] != ''){
+ $email = $_POST['email'];
+ setcookie("email", $email);
+ }
+ }
+ $DOB='';
if (isset($_POST['DOB'])){
if ($_POST['DOB'] != ''){
$DOB = $_POST['DOB'];
header('Location: is_the_information_correct.php');
}
include_once('header.php');
-slack_general('Entering Information','md-petition');
+slack_general('Enter Information ('.$_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:10px; padding:10px; background-color:lightyellow;"><?PHP echo $dX['text_block'];?></h2></div>
</div>
-
+
+ <div class='row'>
+ <div class='col-sm-3' style='text-align:right;'><h2>E-Mail for Follow Up*</h2></div>
+ <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>
+ <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-2' style='height:50px; text-align:right;'><h2>First Name</h2></div>
- <div class='col-sm-6' style='height:50px; text-align:left;'><input class="form-control input-lg" name='web_first_name'></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 oninvalid="this.setCustomValidity('Please enter only your first name')" oninput="this.setCustomValidity('')" ></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-2' style='height:50px; text-align:right;'><h2>Last Name</h2></div>
- <div class='col-sm-6' style='height:50px; text-align:left;'><input class="form-control input-lg" name='web_last_name'></div>
+ <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 oninvalid="this.setCustomValidity('Please enter only your last name')" oninput="this.setCustomValidity('')"></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-2' style='height:50px; text-align:right;'><h2>Date of Birth</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">
- <input name='DOB' type="text" class="form-control"><span class="input-group-addon"><i class="glyphicon glyphicon-th"></i></span>
+ <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('')">
</div>
<script>
- $('.input-group.date').datepicker({
+ var $d = jQuery.noConflict();
+ $d('.input-group.date').datepicker({
format: "mm/dd/yyyy",
clearBtn: true
});
</script>
</div>
- <div>
-
- <div class='row'>
- <div class='col-sm-2' style='height:50px; text-align:center;'><h2>Phone Number</h2></div>
- <div class='col-sm-6' style='height:50px; text-align:center;'><input class="form-control input-lg" name='contact_phone' type='tel'> </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>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 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>
+ <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-2' style='height:50px; text-align:center;'><h2>House Number</h2></div>
- <div class='col-sm-6' style='height:50px; text-align:center;'><input class="form-control input-lg" name='web_house_number' type='number'> </div>
- </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;'></div>
+ </div>
+ <div class='row'>
+ <div class='col-sm-3' style='text-align:right;'><h2>Building 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 oninvalid="this.setCustomValidity('Please enter your house number without street name')" oninput="this.setCustomValidity('')"> </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-2' style='height:50px; text-align:center;'><h2>ZIP Code</h2></div>
- <div class='col-sm-6' style='height:50px; text-align:center;'><input class="form-control input-lg" name='web_zip_code' type='number'> </div>
+ <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>House: 321 Here St.</h3></div>
+ <div class='col-sm-6' style='text-align:left; background-color:lightyellow;'><h3>Use: 321</h3></div>
+ <div class='col-sm-1' style='text-align:center;'></div>
</div>
-
-
<div class='row'>
- <div class='col-sm-4' style='height:50px; text-align:center;'><button type="reset" class="btn btn-warning btn-lg btn-block">Clear</button></div>
- <div class='col-sm-4' 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>Apartment: 21 Here St. Apt 1323</h3></div>
+ <div class='col-sm-6' style='text-align:left; background-color:lightyellow;'><h3>Use: 21</h3></div>
+ <div class='col-sm-1' style='text-align:center;'></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 oninvalid="this.setCustomValidity('Please enter your five digit zip code')" oninput="this.setCustomValidity('')"> </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>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;'></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 alt='Click Here to Continue' 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>
+ <div class='row'>
+ <div class='col-sm-10' style='text-align:center;'>* E-Mail is not required, and will only be used internally, if we need to reach you. It will never sold or given out.</div>
+ </div>
+ <div class='row'>
+ <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>
</div>
-
</form>
<?PHP include_once('footer.php');
HCoop / clinton / MarylandElectronicPetitionSignature.git / blobdiff