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'])){ |
7d59e09c PM |
6 | $email=''; |
7 | if (isset($_POST['email'])){ | |
8 | if ($_POST['email'] != ''){ | |
9 | $email = $_POST['email']; | |
10 | setcookie("email", $email); | |
11 | } | |
12 | } | |
13 | $DOB=''; | |
c1578d40 PM |
14 | if (isset($_POST['DOB'])){ |
15 | if ($_POST['DOB'] != ''){ | |
16 | $DOB = $_POST['DOB']; | |
17 | setcookie("pDOB", $DOB); | |
18 | } | |
19 | } | |
3ce0d58f PM |
20 | $web_first_name=''; |
21 | if (isset($_POST['web_first_name'])){ | |
7a47bfbd | 22 | if ($_POST['web_first_name'] != ''){ |
3ce0d58f | 23 | $web_first_name = $_POST['web_first_name']; |
c114242d | 24 | setcookie("web_first_name", $web_first_name); |
7a47bfbd | 25 | } |
3ce0d58f PM |
26 | } |
27 | $web_last_name=''; | |
28 | if (isset($_POST['web_last_name'])){ | |
7a47bfbd | 29 | if ($_POST['web_last_name'] != ''){ |
3ce0d58f | 30 | $web_last_name = $_POST['web_last_name']; |
c114242d | 31 | setcookie("web_last_name", $web_last_name); |
7a47bfbd | 32 | } |
3ce0d58f | 33 | } |
58c8af47 PM |
34 | if(isset($_POST['web_last_name']) && isset($_POST['web_first_name'])){ |
35 | setcookie("web_name", $web_first_name.' '.$web_last_name); | |
36 | } | |
3ce0d58f PM |
37 | $web_house_number=''; |
38 | if (isset($_POST['web_house_number'])){ | |
7a47bfbd | 39 | if ($_POST['web_house_number'] != ''){ |
3ce0d58f | 40 | $web_house_number = $_POST['web_house_number']; |
c114242d | 41 | setcookie("web_house_number", $web_house_number); |
7a47bfbd | 42 | } |
3ce0d58f PM |
43 | } |
44 | $web_zip_code=''; | |
45 | if (isset($_POST['web_zip_code'])){ | |
7a47bfbd | 46 | if ($_POST['web_zip_code'] != ''){ |
3ce0d58f | 47 | $web_zip_code = $_POST['web_zip_code']; |
c114242d | 48 | setcookie("web_zip_code", $web_zip_code); |
7a47bfbd | 49 | } |
3ce0d58f | 50 | } |
943b1dae PM |
51 | $contact_phone=''; |
52 | if (isset($_POST['contact_phone'])){ | |
53 | if ($_POST['contact_phone'] != ''){ | |
54 | $contact_phone = $_POST['contact_phone']; | |
60e76c2f | 55 | setcookie("pPHONE", $contact_phone); |
943b1dae PM |
56 | } |
57 | } | |
eb2d265f | 58 | header('Location: is_the_information_correct.php'); |
3ce0d58f | 59 | } |
aa92c8ea | 60 | include_once('header.php'); |
1c16fad8 | 61 | slack_general('Enter Information ('.$_COOKIE['invite'].')','md-petition'); |
8438eadf PM |
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 | |
87824afc PM |
66 | $qX = "select * from website_text where id = '2'"; |
67 | $rX = $petition->query($qX); | |
68 | $dX = mysqli_fetch_array($rX); | |
4f46b65a | 69 | ?> |
36a3bd9e | 70 | <script>document.title = "MEPS - Enter Information";</script> |
4f46b65a | 71 | <form method='POST'> |
72eb3929 | 72 | |
13269a9f | 73 | <div class='row'> |
7d59e09c | 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> |
c1578d40 | 75 | </div> |
a4b12b0c | 76 | |
7d59e09c PM |
77 | |
78 | <div class='row'> | |
32713b7f | 79 | <div class='col-sm-3' style='text-align:right;'><h2>E-Mail for Follow Up*</h2></div> |
008e034f | 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> |
7d59e09c PM |
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> | |
43364c37 | 83 | |
c1578d40 | 84 | <div class='row'> |
439d49cd | 85 | <div class='col-sm-3' style='text-align:right;'><h2>First Name</h2></div> |
008e034f | 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> |
d2e9d56d | 87 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> |
aa47a038 | 88 | </div> |
13269a9f | 89 | |
c1578d40 | 90 | <div class='row'> |
439d49cd | 91 | <div class='col-sm-3' style='text-align:right;'><h2>Last Name</h2></div> |
008e034f | 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> |
d2e9d56d | 93 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> |
13269a9f PM |
94 | </div> |
95 | ||
aa47a038 | 96 | <div class='row'> |
439d49cd | 97 | <div class='col-sm-3' style='text-align:right;'><h2>Date of Birth</h2></div> |
43364c37 | 98 | <div class='col-sm-6'> |
4361cfcc | 99 | <div class="input-group date"> |
008e034f | 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('')"> |
93ecf6c1 | 101 | </div> |
4361cfcc | 102 | <script> |
883c0e81 PM |
103 | var $d = jQuery.noConflict(); |
104 | $d('.input-group.date').datepicker({ | |
4361cfcc PM |
105 | format: "mm/dd/yyyy", |
106 | clearBtn: true | |
107 | }); | |
108 | </script> | |
5ca4bf82 | 109 | </div> |
d2e9d56d | 110 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> |
43364c37 | 111 | </div> |
62c99d79 | 112 | <div class='row'> |
32713b7f | 113 | <div class='col-sm-3' style='text-align:right;'><h2>Phone Number**</h2></div> |
008e034f | 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> |
d2e9d56d | 115 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</div> |
13269a9f | 116 | </div> |
f32af605 | 117 | <div class='row'> |
43364c37 PM |
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> | |
407ced6d | 120 | <div class='col-sm-1' style='text-align:center;'></div> |
62c99d79 | 121 | </div> |
c1578d40 | 122 | <div class='row'> |
407ced6d | 123 | <div class='col-sm-3' style='text-align:right;'><h2>Building Number</h2></div> |
008e034f | 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> |
d2e9d56d | 125 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> |
43364c37 | 126 | </div> |
f32af605 | 127 | <div class='row'> |
407ced6d PM |
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> | |
5ca4bf82 | 137 | <div class='row'> |
439d49cd | 138 | <div class='col-sm-3' style='text-align:right;'><h2>ZIP Code</h2></div> |
008e034f | 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> |
d2e9d56d | 140 | <div class='col-sm-1' style='text-align:center;'><button type="submit" class="btn btn-success btn-lg btn-block">↴</button></div> |
c1578d40 | 141 | </div> |
f32af605 | 142 | <div class='row'> |
43364c37 PM |
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> | |
407ced6d | 145 | <div class='col-sm-1' style='text-align:center;'></div> |
62c99d79 | 146 | </div> |
43364c37 | 147 | <div class='row'> |
655993ca | 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> |
72eb3929 | 149 | </div> |
43364c37 PM |
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> | |
32713b7f PM |
153 | <div class='row'> |
154 | <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> | |
155 | </div> | |
156 | <div class='row'> | |
157 | <div class='col-sm-10' style='text-align:center;'>** WE WILL NEVER USE YOUR PHONE NUMBER - NEVER CALL - NEVER FOR TEXT MESSAGES.</div> | |
158 | </div> | |
4f46b65a | 159 | </form> |
13269a9f | 160 | |
09a581dc | 161 | <?PHP include_once('footer.php'); |