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);
<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='row'>
- <div class='col-sm-6' style='height:50px; text-align:center;'><input class="form-control input-lg" name='web_first_name'></div>
- <div class='col-sm-6' style='height:50px; text-align:center;'><input class="form-control input-lg" name='web_last_name'></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>
<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>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>
-
- <div class="row">
- <div class='col-sm-6'>
- <div class="form-group">
- <div class='input-group date' id='datetimepicker3'>
- <input name='DOB' type='text' class="form-control input-lg" />
- <span class="input-group-addon">
- <span class="glyphicon glyphicon-time"></span>
- </span>
- </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="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>
- </div>
- <script type="text/javascript">
- $(function () {
- $('#datetimepicker3').datetimepicker({
- format: 'LT'
- });
- });
- </script>
-
-
-
-
-
-
-
- <div class='col-sm-6' style='height:50px; text-align:center;'><input class="form-control input-lg" name='contact_phone' type='tel'> </div>
+ <script>
+ 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-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" type="tel" id="contact_phone" name="contact_phone" pattern="[0-9]{3}-[0-9]{3}-[0-9]{4}" required></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-7' style='text-align:left; background-color:lightyellow;'><h3>443-123-4567</h3></div>
</div>
<div class='row'>
- <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 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;'><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='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='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>
+ <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>
<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-5' style='text-align:center;'><button type="reset" class="btn btn-warning btn-lg btn-block">Clear</button></div>
+ <div class='col-sm-5' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">Next</button></div>
</div>
</form>