+++ /dev/null
-<?PHP
-if (empty($_COOKIE['signature_status'])){
- setcookie("signature_status", 'unverified');
-}
-if (isset($_POST['web_first_name'])){
- $email='';
- if (isset($_POST['email'])){
- if ($_POST['email'] != ''){
- $email = $_POST['email'];
- setcookie("email", $email);
- }
- }
- $DOB='';
- // old DOB form
- if (isset($_POST['DOB'])){
- if ($_POST['DOB'] != ''){
- $DOB = $_POST['DOB'];
- setcookie("pDOB", $DOB);
- }
- }
- // new DOB form
- if (isset($_POST['web_dob_day'])){
- if ($_POST['web_dob_day'] != ''){
- $DOB = intval($_POST['web_dob_year']).'-'.intval($_POST['web_dob_month']).'-'.intval($_POST['web_dob_day']);
- setcookie("pDOB", $DOB);
- setcookie("web_dob_month", $_POST['web_dob_month']);
- setcookie("web_dob_year", $_POST['web_dob_year']);
- setcookie("web_dob_day", $_POST['web_dob_day']);
- }
- }
- $web_first_name='';
- if (isset($_POST['web_first_name'])){
- if ($_POST['web_first_name'] != ''){
- $web_first_name = $_POST['web_first_name'];
- setcookie("web_first_name", $web_first_name);
- }
- }
- $web_last_name='';
- if (isset($_POST['web_last_name'])){
- if ($_POST['web_last_name'] != ''){
- $web_last_name = $_POST['web_last_name'];
- setcookie("web_last_name", $web_last_name);
- }
- }
- if(isset($_POST['web_last_name']) && isset($_POST['web_first_name'])){
- setcookie("web_name", $web_first_name.' '.$web_last_name);
- }
- $web_house_number='';
- if (isset($_POST['web_house_number'])){
- if ($_POST['web_house_number'] != ''){
- $web_house_number = intval($_POST['web_house_number']);
- setcookie("web_house_number", $web_house_number);
- }
- }
- $web_zip_code='';
- if (isset($_POST['web_zip_code'])){
- if ($_POST['web_zip_code'] != ''){
- $web_zip_code = substr(intval($_POST['web_zip_code']),0,5);
- 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='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-3' style='text-align:right;'><h2>Date of Birth</h2></div>
- <div class='col-sm-2' style='text-align:left;'><input type='number' class="form-control input-lg" name='web_dob_month' required oninvalid="this.setCustomValidity('Please enter the month you were born.')" oninput="this.setCustomValidity('')"></div>
- <div class='col-sm-2' style='text-align:left;'><input type='number' class="form-control input-lg" name='web_dob_day' required oninvalid="this.setCustomValidity('Please the day you were born.')" oninput="this.setCustomValidity('')"></div>
- <div class='col-sm-2' style='text-align:left;'><input type='number' class="form-control input-lg" name='web_dob_year' required oninvalid="this.setCustomValidity('Please enter the year you were born.')" 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>Date of Birth Format</h3></div>
- <div class='col-sm-2' style='text-align:left; background-color:lightyellow;'><h3>MM</h3></div>
- <div class='col-sm-2' style='text-align:left; background-color:lightyellow;'><h3>DD</h3></div>
- <div class='col-sm-2' style='text-align:left; background-color:lightyellow;'><h3>YYYY</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>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-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-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-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-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;'>* E-Mail is not required, it will only be used internally 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');