header('Location: is_the_information_correct.php');
}
include_once('header.php');
+slack_general('Entering Information','md-petition');
$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;'><h3><?PHP echo $dX['text_title'];?></h3><p style="margin:25px; padding25px; background-color:lightyellow;"><?PHP echo $dX['text_block'];?></p></div>
+ <div class='row'>
+ <div class='col-sm-8' 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-4' style='height:50px; text-align:center;'><h3>First Name</h3></div>
- <div class='col-sm-4' style='height:50px; text-align:center;'><h3>Last Name</h3></div>
- <div class='col-sm-4' style='height:50px; text-align:center;'><h3>Date of Birth</h3></div>
- </div>
+ <div class='col-sm-3' style='text-align:right;'><h2>First Name</h2></div>
+ <div class='col-sm-5' style='text-align:left;'><input class="form-control input-lg" name='web_first_name'></div>
+ </div>
+
<div class='row'>
- <div class='col-sm-4' style='height:50px; text-align:center;'><input name='web_first_name'></div>
- <div class='col-sm-4' style='height:50px; text-align:center;'><input name='web_last_name'></div>
- <div class='col-sm-4' style='height:50px; text-align:center;'><input name='DOB' type="date"></div>
- </div>
+ <div class='col-sm-3' style='text-align:right;'><h2>Last Name</h2></div>
+ <div class='col-sm-5' style='text-align:left;'><input class="form-control input-lg" name='web_last_name'></div>
+ </div>
+
<div class='row'>
- <div class='col-sm-4' style='height:50px; text-align:center;'><h3>House Number</h3></div>
- <div class='col-sm-4' style='height:50px; text-align:center;'><h3>ZIP Code</h3></div>
- <div class='col-sm-4' style='height:50px; text-align:center;'><h3>Phone Number</h3></div>
+ <div class='col-sm-3' style='text-align:right;'><h2>Date of Birth</h2></div>
+ <div class='col-sm-5'>
+ <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">
+ </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-5' style='text-align:left;'><input class="form-control input-lg" name='contact_phone' type='tel'> </div>
</div>
+
+ <div class='row'>
+ <div class='col-sm-3' style='text-align:right;'><h2>House Number</h2></div>
+ <div class='col-sm-5' style='text-align:left;'><input class="form-control input-lg" name='web_house_number' type='number'> </div>
+ </div>
+
<div class='row'>
- <div class='col-sm-4' style='height:50px; text-align:center;'><input name='web_house_number' type='number'> </div>
- <div class='col-sm-4' style='height:50px; text-align:center;'><input name='web_zip_code' type='number'> </div>
- <div class='col-sm-4' style='height:50px; text-align:center;'><input name='contact_phone' type='tel'> </div>
+ <div class='col-sm-3' style='text-align:right;'><h2>ZIP Code</h2></div>
+ <div class='col-sm-5' style='text-align:left;'><input class="form-control input-lg" name='web_zip_code' type='number'> </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-4' style='text-align:center;'><button type="reset" class="btn btn-warning btn-lg btn-block">Clear</button></div>
+ <div class='col-sm-4' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">Next</button></div>
</div>
+
</form>
+
<?PHP include_once('footer.php');