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Create header.php
[clinton/MarylandElectronicPetitionSignature.git] / enter_information.php
diff --git a/enter_information.php b/enter_information.php
index 9a2d87b..6d1be7b 100644 (file)
--- a/enter_information.php
+++ b/enter_information.php
@@ -67,22 +67,24 @@ slack_general('Enter Information ('.$_COOKIE['invite'].')','md-petition');
     <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-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-3' style='text-align:right;'><h2>First Name</h2></div>
-    <div class='col-sm-7' style='text-align:left;'><input class="form-control input-lg" name='web_first_name' required></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-3' style='text-align:right;'><h2>Last Name</h2></div>
-     <div class='col-sm-7' style='text-align:left;'><input class="form-control input-lg" name='web_last_name' required></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-3' style='text-align:right;'><h2>Date of Birth</h2></div>
-     <div class='col-sm-7'>
+     <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>
@@ -94,43 +96,44 @@ slack_general('Enter Information ('.$_COOKIE['invite'].')','md-petition');
                });
          </script>
        </div>
-   </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-7' 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-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-3' style='text-align:right; background-color:lightyellow;'><h3>Phone Format</h3></div>
-     <div class='col-sm-7' style='text-align:left; background-color:lightyellow;'><h3>443-123-4567</h3></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-3' style='text-align:right;'><h2>House Number</h2></div>
-    <div class='col-sm-7' style='text-align:left;'><input class="form-control input-lg" name='web_house_number' type='number' required> </div>
- </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-7' style='text-align:left; background-color:lightyellow;'><h3>321</h3></div>
-  </div>
-         
+     <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-7' style='text-align:left;'><input class="form-control input-lg" name='web_zip_code' type='number' required> </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-3' style='text-align:right; background-color:lightyellow;'><h3>ZIP Code Format</h3></div>
-     <div class='col-sm-7' style='text-align:left; background-color:lightyellow;'><h3>55555</h3></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='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>
+  <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');
Unnamed repository; edit this file 'description' to name the repository.