Commit | Line | Data |
---|---|---|
48b7f170 PM |
1 | <?PHP |
2 | if (empty($_COOKIE['signature_status'])){ | |
3 | setcookie("signature_status", 'unverified'); | |
4 | } | |
5 | if (isset($_POST['web_first_name'])){ | |
6 | $email=''; | |
7 | if (isset($_POST['email'])){ | |
8 | if ($_POST['email'] != ''){ | |
9 | $email = $_POST['email']; | |
10 | setcookie("email", $email); | |
11 | } | |
12 | } | |
13 | $DOB=''; | |
14 | if (isset($_POST['DOB'])){ | |
15 | if ($_POST['DOB'] != ''){ | |
16 | $DOB = $_POST['DOB']; | |
17 | setcookie("pDOB", $DOB); | |
18 | } | |
19 | } | |
20 | $web_first_name=''; | |
21 | if (isset($_POST['web_first_name'])){ | |
22 | if ($_POST['web_first_name'] != ''){ | |
23 | $web_first_name = $_POST['web_first_name']; | |
24 | setcookie("web_first_name", $web_first_name); | |
25 | } | |
26 | } | |
27 | $web_last_name=''; | |
28 | if (isset($_POST['web_last_name'])){ | |
29 | if ($_POST['web_last_name'] != ''){ | |
30 | $web_last_name = $_POST['web_last_name']; | |
31 | setcookie("web_last_name", $web_last_name); | |
32 | } | |
33 | } | |
34 | if(isset($_POST['web_last_name']) && isset($_POST['web_first_name'])){ | |
35 | setcookie("web_name", $web_first_name.' '.$web_last_name); | |
36 | } | |
37 | $web_house_number=''; | |
38 | if (isset($_POST['web_house_number'])){ | |
39 | if ($_POST['web_house_number'] != ''){ | |
40 | $web_house_number = $_POST['web_house_number']; | |
41 | setcookie("web_house_number", $web_house_number); | |
42 | } | |
43 | } | |
44 | $web_zip_code=''; | |
45 | if (isset($_POST['web_zip_code'])){ | |
46 | if ($_POST['web_zip_code'] != ''){ | |
47 | $web_zip_code = $_POST['web_zip_code']; | |
48 | setcookie("web_zip_code", $web_zip_code); | |
49 | } | |
50 | } | |
51 | $contact_phone=''; | |
52 | if (isset($_POST['contact_phone'])){ | |
53 | if ($_POST['contact_phone'] != ''){ | |
54 | $contact_phone = $_POST['contact_phone']; | |
55 | setcookie("pPHONE", $contact_phone); | |
56 | } | |
57 | } | |
58 | header('Location: is_the_information_correct.php'); | |
59 | } | |
60 | include_once('header.php'); | |
61 | slack_general('Enter Information ('.$_COOKIE['invite'].')','md-petition'); | |
62 | ?> | |
63 | <link id="bsdp-css" href="files/bootstrap-datepicker3.min.css" rel="stylesheet"> | |
64 | <script src="files/bootstrap-datepicker.min.js"></script> | |
65 | <?PHP | |
66 | $qX = "select * from website_text where id = '2'"; | |
67 | $rX = $petition->query($qX); | |
68 | $dX = mysqli_fetch_array($rX); | |
69 | ?> | |
70 | <script>document.title = "MEPS - Enter Information";</script> | |
71 | <form method='POST'> | |
72 | ||
73 | <div class='row'> | |
74 | <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> | |
75 | </div> | |
76 | ||
77 | ||
78 | <div class='row'> | |
79 | <div class='col-sm-3' style='text-align:right;'><h2>E-Mail for Follow Up*</h2></div> | |
80 | <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> | |
81 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> | |
82 | </div> | |
83 | ||
84 | <div class='row'> | |
85 | <div class='col-sm-3' style='text-align:right;'><h2>First Name</h2></div> | |
86 | <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> | |
87 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> | |
88 | </div> | |
89 | ||
90 | <div class='row'> | |
91 | <div class='col-sm-3' style='text-align:right;'><h2>Last Name</h2></div> | |
92 | <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> | |
93 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> | |
94 | </div> | |
95 | ||
96 | <div class='row'> | |
97 | <div class='col-sm-3' style='text-align:right;'><h2>Date of Birth</h2></div> | |
98 | <div class='col-sm-6'> | |
99 | <div class="input-group date"> | |
100 | <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('')"> | |
101 | </div> | |
102 | <script> | |
103 | var $d = jQuery.noConflict(); | |
104 | $d('.input-group.date').datepicker({ | |
105 | format: "mm/dd/yyyy", | |
106 | clearBtn: true | |
107 | }); | |
108 | </script> | |
109 | </div> | |
110 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> | |
111 | </div> | |
112 | <div class='row'> | |
113 | <div class='col-sm-3' style='text-align:right;'><h2>Phone Number**</h2></div> | |
114 | <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> | |
115 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</div> | |
116 | </div> | |
117 | <div class='row'> | |
118 | <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>Phone Format</h3></div> | |
119 | <div class='col-sm-6' style='text-align:left; background-color:lightyellow;'><h3>443-123-4567</h3></div> | |
120 | <div class='col-sm-1' style='text-align:center;'></div> | |
121 | </div> | |
122 | <div class='row'> | |
123 | <div class='col-sm-3' style='text-align:right;'><h2>Building Number</h2></div> | |
124 | <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> | |
125 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> | |
126 | </div> | |
127 | <div class='row'> | |
128 | <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>House: 321 Here St.</h3></div> | |
129 | <div class='col-sm-6' style='text-align:left; background-color:lightyellow;'><h3>Use: 321</h3></div> | |
130 | <div class='col-sm-1' style='text-align:center;'></div> | |
131 | </div> | |
132 | <div class='row'> | |
133 | <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>Apartment: 21 Here St. Apt 1323</h3></div> | |
134 | <div class='col-sm-6' style='text-align:left; background-color:lightyellow;'><h3>Use: 21</h3></div> | |
135 | <div class='col-sm-1' style='text-align:center;'></div> | |
136 | </div> | |
137 | <div class='row'> | |
138 | <div class='col-sm-3' style='text-align:right;'><h2>ZIP Code</h2></div> | |
139 | <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> | |
140 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> | |
141 | </div> | |
142 | <div class='row'> | |
143 | <div class='col-sm-3' style='text-align:right; background-color:lightyellow;'><h3>ZIP Code Format</h3></div> | |
144 | <div class='col-sm-6' style='text-align:left; background-color:lightyellow;'><h3>55555</h3></div> | |
145 | <div class='col-sm-1' style='text-align:center;'></div> | |
146 | </div> | |
147 | <div class='row'> | |
148 | <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> | |
149 | </div> | |
150 | <div class='row'> | |
151 | <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> | |
152 | </div> | |
153 | <div class='row'> | |
154 | <div class='col-sm-10' style='text-align:center;'>* E-Mail is not required, and will only be used with the petitioners to reach you. It will never be sold.</div> | |
155 | </div> | |
156 | <div class='row'> | |
157 | <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> | |
158 | </div> | |
159 | </form> | |
160 | ||
161 | <?PHP include_once('footer.php'); |