Commit | Line | Data |
---|---|---|
4f46b65a | 1 | <?PHP |
97cefac7 PM |
2 | if (empty($_COOKIE['signature_status'])){ |
3 | setcookie("signature_status", 'unverified'); | |
4 | } | |
eb2d265f | 5 | if (isset($_POST['web_first_name'])){ |
c1578d40 PM |
6 | $DOB=''; |
7 | if (isset($_POST['DOB'])){ | |
8 | if ($_POST['DOB'] != ''){ | |
9 | $DOB = $_POST['DOB']; | |
10 | setcookie("pDOB", $DOB); | |
11 | } | |
12 | } | |
3ce0d58f PM |
13 | $web_first_name=''; |
14 | if (isset($_POST['web_first_name'])){ | |
7a47bfbd | 15 | if ($_POST['web_first_name'] != ''){ |
3ce0d58f | 16 | $web_first_name = $_POST['web_first_name']; |
c114242d | 17 | setcookie("web_first_name", $web_first_name); |
7a47bfbd | 18 | } |
3ce0d58f PM |
19 | } |
20 | $web_last_name=''; | |
21 | if (isset($_POST['web_last_name'])){ | |
7a47bfbd | 22 | if ($_POST['web_last_name'] != ''){ |
3ce0d58f | 23 | $web_last_name = $_POST['web_last_name']; |
c114242d | 24 | setcookie("web_last_name", $web_last_name); |
7a47bfbd | 25 | } |
3ce0d58f | 26 | } |
58c8af47 PM |
27 | if(isset($_POST['web_last_name']) && isset($_POST['web_first_name'])){ |
28 | setcookie("web_name", $web_first_name.' '.$web_last_name); | |
29 | } | |
3ce0d58f PM |
30 | $web_house_number=''; |
31 | if (isset($_POST['web_house_number'])){ | |
7a47bfbd | 32 | if ($_POST['web_house_number'] != ''){ |
3ce0d58f | 33 | $web_house_number = $_POST['web_house_number']; |
c114242d | 34 | setcookie("web_house_number", $web_house_number); |
7a47bfbd | 35 | } |
3ce0d58f PM |
36 | } |
37 | $web_zip_code=''; | |
38 | if (isset($_POST['web_zip_code'])){ | |
7a47bfbd | 39 | if ($_POST['web_zip_code'] != ''){ |
3ce0d58f | 40 | $web_zip_code = $_POST['web_zip_code']; |
c114242d | 41 | setcookie("web_zip_code", $web_zip_code); |
7a47bfbd | 42 | } |
3ce0d58f | 43 | } |
943b1dae PM |
44 | $contact_phone=''; |
45 | if (isset($_POST['contact_phone'])){ | |
46 | if ($_POST['contact_phone'] != ''){ | |
47 | $contact_phone = $_POST['contact_phone']; | |
60e76c2f | 48 | setcookie("pPHONE", $contact_phone); |
943b1dae PM |
49 | } |
50 | } | |
eb2d265f | 51 | header('Location: is_the_information_correct.php'); |
3ce0d58f | 52 | } |
aa92c8ea | 53 | include_once('header.php'); |
1c16fad8 | 54 | slack_general('Enter Information ('.$_COOKIE['invite'].')','md-petition'); |
8438eadf PM |
55 | ?> |
56 | <link id="bsdp-css" href="files/bootstrap-datepicker3.min.css" rel="stylesheet"> | |
57 | <script src="files/bootstrap-datepicker.min.js"></script> | |
58 | <?PHP | |
87824afc PM |
59 | $qX = "select * from website_text where id = '2'"; |
60 | $rX = $petition->query($qX); | |
61 | $dX = mysqli_fetch_array($rX); | |
4f46b65a | 62 | ?> |
36a3bd9e | 63 | <script>document.title = "MEPS - Enter Information";</script> |
4f46b65a | 64 | <form method='POST'> |
a4b12b0c | 65 | |
13269a9f | 66 | <div class='row'> |
b1cc69f2 | 67 | <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> |
c1578d40 | 68 | </div> |
a4b12b0c | 69 | |
aa47a038 | 70 | |
c1578d40 | 71 | <div class='row'> |
439d49cd | 72 | <div class='col-sm-3' style='text-align:right;'><h2>First Name</h2></div> |
09e60f8e | 73 | <div class='col-sm-7' style='text-align:left;'><input class="form-control input-lg" name='web_first_name' required></div> |
aa47a038 | 74 | </div> |
13269a9f | 75 | |
c1578d40 | 76 | <div class='row'> |
439d49cd | 77 | <div class='col-sm-3' style='text-align:right;'><h2>Last Name</h2></div> |
09e60f8e | 78 | <div class='col-sm-7' style='text-align:left;'><input class="form-control input-lg" name='web_last_name' required></div> |
13269a9f PM |
79 | </div> |
80 | ||
aa47a038 | 81 | <div class='row'> |
439d49cd | 82 | <div class='col-sm-3' style='text-align:right;'><h2>Date of Birth</h2></div> |
b1cc69f2 | 83 | <div class='col-sm-7'> |
4361cfcc | 84 | <div class="input-group date"> |
09e60f8e | 85 | <span class="input-group-addon"><i class="glyphicon glyphicon-th"></i></span><input name='DOB' type="text" class="form-control" required> |
93ecf6c1 | 86 | </div> |
4361cfcc | 87 | <script> |
883c0e81 PM |
88 | var $d = jQuery.noConflict(); |
89 | $d('.input-group.date').datepicker({ | |
4361cfcc PM |
90 | format: "mm/dd/yyyy", |
91 | clearBtn: true | |
92 | }); | |
93 | </script> | |
5ca4bf82 | 94 | </div> |
439d49cd | 95 | </div> |
aa47a038 | 96 | |
62c99d79 | 97 | <div class='row'> |
439d49cd | 98 | <div class='col-sm-3' style='text-align:right;'><h2>Phone Number</h2></div> |
55694cb0 | 99 | <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> |
13269a9f | 100 | </div> |
62c99d79 PM |
101 | <div class='row' style='background-color:lightyellow;'> |
102 | <div class='col-sm-3' style='text-align:right;'><h3>Phone Format</h3></div> | |
103 | <div class='col-sm-7' style='text-align:left;'><h3>443-123-4567</h3></div> | |
104 | </div> | |
13269a9f | 105 | |
c1578d40 | 106 | <div class='row'> |
439d49cd | 107 | <div class='col-sm-3' style='text-align:right;'><h2>House Number</h2></div> |
09e60f8e | 108 | <div class='col-sm-7' style='text-align:left;'><input class="form-control input-lg" name='web_house_number' type='number' required> </div> |
aa47a038 | 109 | </div> |
62c99d79 PM |
110 | |
111 | <div class='row' style='background-color:lightyellow;'> | |
112 | <div class='col-sm-3' style='text-align:right;'><h3>House Number Format</h3></div> | |
113 | <div class='col-sm-7' style='text-align:left;'><h3>321</h3></div> | |
114 | </div> | |
115 | ||
5ca4bf82 | 116 | <div class='row'> |
439d49cd | 117 | <div class='col-sm-3' style='text-align:right;'><h2>ZIP Code</h2></div> |
09e60f8e | 118 | <div class='col-sm-7' style='text-align:left;'><input class="form-control input-lg" name='web_zip_code' type='number' required> </div> |
c1578d40 | 119 | </div> |
13269a9f | 120 | |
62c99d79 PM |
121 | <div class='row' style='background-color:lightyellow;'> |
122 | <div class='col-sm-3' style='text-align:right;'><h3>ZIP Code Format</h3></div> | |
123 | <div class='col-sm-7' style='text-align:left;'><h3>55555</h3></div> | |
124 | </div> | |
13269a9f | 125 | |
c1578d40 | 126 | <div class='row'> |
b1cc69f2 PM |
127 | <div class='col-sm-5' style='text-align:center;'><button type="reset" class="btn btn-warning btn-lg btn-block">Clear</button></div> |
128 | <div class='col-sm-5' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">Next</button></div> | |
c1578d40 | 129 | </div> |
13269a9f | 130 | |
4f46b65a | 131 | </form> |
13269a9f | 132 | |
09a581dc | 133 | <?PHP include_once('footer.php'); |