X-Git-Url: http://git.hcoop.net/clinton/MarylandElectronicPetitionSignature.git/blobdiff_plain/f406b58f2c4464ee1341790b64c4dfe5a9f6a529..5c5b10ac2ff5e62e532452b0ce7b6f978ed95e4f:/enter_information.php

diff --git a/enter_information.php b/enter_information.php
index 46a8c2d..58ca9b0 100644
--- a/enter_information.php
+++ b/enter_information.php
@@ -3,7 +3,14 @@ if (empty($_COOKIE['signature_status'])){
    setcookie("signature_status", 'unverified');
 }
 if (isset($_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 = $_POST['DOB'];
@@ -51,38 +58,104 @@ if (isset($_POST['web_first_name'])){
   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='row'>
+    <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-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-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-12' style='height:100px; text-align:center;'><h2><?PHP echo $dX['text_title'];?></h2><p style="margin:25px; padding25px; background-color:lightyellow;"><?PHP echo $dX['text_block'];?></p></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">
+              <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>
+               var $d = jQuery.noConflict();
+               $d('.input-group.date').datepicker({
+                   format: "mm/dd/yyyy",
+                   clearBtn: true
+               });
+         </script>
+       </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-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-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;'><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 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-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; 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-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-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-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-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-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-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');