<?PHP
+if (empty($_COOKIE['signature_status'])){
+ setcookie("signature_status", 'unverified');
+}
if (isset($_POST['web_first_name'])){
+ $DOB='';
+ if (isset($_POST['DOB'])){
+ if ($_POST['DOB'] != ''){
+ $DOB = $_POST['DOB'];
+ setcookie("pDOB", $DOB);
+ }
+ }
$web_first_name='';
if (isset($_POST['web_first_name'])){
if ($_POST['web_first_name'] != ''){
setcookie("web_zip_code", $web_zip_code);
}
}
+ $contact_phone='';
+ if (isset($_POST['contact_phone'])){
+ if ($_POST['contact_phone'] != ''){
+ $contact_phone = $_POST['contact_phone'];
+ setcookie("pPHONE", $contact_phone);
+ }
+ }
header('Location: is_the_information_correct.php');
}
include_once('header.php');
+slack_general('Enter Information ('.$_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='col-sm-12' style='height:100px; text-align:center;'><h3>Please enter your Name and ZIP Code as it appears on your Maryland Voter Registration</h3></div>
-
- <div class='col-sm-6' style='height:50px; text-align:center;'><h3>First Name</h3></div>
-
- <div class='col-sm-6' style='height:50px; text-align:center;'><h3>Last Name</h3></div>
-
- <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='col-sm-6' style='height:50px; text-align:center;'><h3>House Number</h3></div>
-
- <div class='col-sm-6' style='height:50px; text-align:center;'><h3>ZIP Code</h3></div>
-
- <div class='col-sm-6' style='height:50px; text-align:center;'><input name='web_house_number'> </div>
-
- <div class='col-sm-6' style='height:50px; text-align:center;'><input name='web_zip_code'> </div>
-
- <div class='col-sm-12' style='height:50px; text-align:center;'><button type="submit" class="btn btn-success">Next</button></div>
-
- <div class='col-sm-12' style='height:50px; text-align:center;'><button type="reset" class="btn btn-warning">Clear</button></div>
-
+ <div class='row'>
+ <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-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-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-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>
+ <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-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-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-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>
<?PHP include_once('footer.php');