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'); |
d4242086 | 54 | slack_general('Entering Information','md-petition'); |
87824afc PM |
55 | $qX = "select * from website_text where id = '2'"; |
56 | $rX = $petition->query($qX); | |
57 | $dX = mysqli_fetch_array($rX); | |
4f46b65a | 58 | ?> |
36a3bd9e | 59 | <script>document.title = "MEPS - Enter Information";</script> |
4f46b65a | 60 | <form method='POST'> |
a4b12b0c | 61 | |
13269a9f | 62 | <div class='row'> |
439d49cd | 63 | <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> |
c1578d40 | 64 | </div> |
a4b12b0c | 65 | |
aa47a038 | 66 | |
c1578d40 | 67 | <div class='row'> |
439d49cd PM |
68 | <div class='col-sm-3' style='text-align:right;'><h2>First Name</h2></div> |
69 | <div class='col-sm-5' style='text-align:left;'><input class="form-control input-lg" name='web_first_name'></div> | |
aa47a038 | 70 | </div> |
13269a9f | 71 | |
c1578d40 | 72 | <div class='row'> |
439d49cd PM |
73 | <div class='col-sm-3' style='text-align:right;'><h2>Last Name</h2></div> |
74 | <div class='col-sm-5' style='text-align:left;'><input class="form-control input-lg" name='web_last_name'></div> | |
13269a9f PM |
75 | </div> |
76 | ||
aa47a038 | 77 | <div class='row'> |
439d49cd PM |
78 | <div class='col-sm-3' style='text-align:right;'><h2>Date of Birth</h2></div> |
79 | <div class='col-sm-5'> | |
4361cfcc | 80 | <div class="input-group date"> |
76e48b4f | 81 | <span class="input-group-addon"><i class="glyphicon glyphicon-th"></i></span><input name='DOB' type="text" class="form-control"> |
93ecf6c1 | 82 | </div> |
4361cfcc PM |
83 | <script> |
84 | $('.input-group.date').datepicker({ | |
85 | format: "mm/dd/yyyy", | |
86 | clearBtn: true | |
87 | }); | |
88 | </script> | |
5ca4bf82 | 89 | </div> |
439d49cd | 90 | </div> |
aa47a038 | 91 | |
5ca4bf82 | 92 | <div class='row'> |
439d49cd PM |
93 | <div class='col-sm-3' style='text-align:right;'><h2>Phone Number</h2></div> |
94 | <div class='col-sm-5' style='text-align:left;'><input class="form-control input-lg" name='contact_phone' type='tel'> </div> | |
13269a9f PM |
95 | </div> |
96 | ||
c1578d40 | 97 | <div class='row'> |
439d49cd PM |
98 | <div class='col-sm-3' style='text-align:right;'><h2>House Number</h2></div> |
99 | <div class='col-sm-5' style='text-align:left;'><input class="form-control input-lg" name='web_house_number' type='number'> </div> | |
aa47a038 PM |
100 | </div> |
101 | ||
5ca4bf82 | 102 | <div class='row'> |
439d49cd PM |
103 | <div class='col-sm-3' style='text-align:right;'><h2>ZIP Code</h2></div> |
104 | <div class='col-sm-5' style='text-align:left;'><input class="form-control input-lg" name='web_zip_code' type='number'> </div> | |
c1578d40 | 105 | </div> |
13269a9f PM |
106 | |
107 | ||
c1578d40 | 108 | <div class='row'> |
439d49cd PM |
109 | <div class='col-sm-4' style='text-align:center;'><button type="reset" class="btn btn-warning btn-lg btn-block">Clear</button></div> |
110 | <div class='col-sm-4' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">Next</button></div> | |
c1578d40 | 111 | </div> |
13269a9f | 112 | |
4f46b65a | 113 | </form> |
13269a9f | 114 | |
09a581dc | 115 | <?PHP include_once('footer.php'); |