enter_information.php

   1 <?PHP
   2 if (empty($_COOKIE['signature_status'])){
   3    setcookie("signature_status", 'unverified');
   4 }
   5 if (isset($_POST['web_first_name'])){
   6   $DOB='';
   7   if (isset($_POST['DOB'])){
   8     if ($_POST['DOB'] != ''){
   9      $DOB = $_POST['DOB'];
  10      setcookie("pDOB", $DOB);
  11     }
  12   }
  13   $web_first_name='';
  14   if (isset($_POST['web_first_name'])){
  15     if ($_POST['web_first_name'] != ''){
  16      $web_first_name = $_POST['web_first_name'];
  17      setcookie("web_first_name", $web_first_name);
  18     }
  19   }
  20   $web_last_name='';
  21   if (isset($_POST['web_last_name'])){
  22     if ($_POST['web_last_name'] != ''){
  23      $web_last_name = $_POST['web_last_name'];
  24      setcookie("web_last_name", $web_last_name);
  25     }
  26   }
  27   if(isset($_POST['web_last_name']) && isset($_POST['web_first_name'])){
  28      setcookie("web_name", $web_first_name.' '.$web_last_name);
  29   }
  30   $web_house_number='';
  31   if (isset($_POST['web_house_number'])){
  32     if ($_POST['web_house_number'] != ''){
  33      $web_house_number = $_POST['web_house_number'];
  34      setcookie("web_house_number", $web_house_number);
  35     }
  36   }
  37   $web_zip_code='';
  38   if (isset($_POST['web_zip_code'])){
  39     if ($_POST['web_zip_code'] != ''){
  40      $web_zip_code = $_POST['web_zip_code'];
  41      setcookie("web_zip_code", $web_zip_code);
  42     }
  43   }
  44   $contact_phone='';
  45   if (isset($_POST['contact_phone'])){
  46     if ($_POST['contact_phone'] != ''){
  47      $contact_phone = $_POST['contact_phone'];
  48      setcookie("pPHONE", $contact_phone);
  49     }
  50   }
  51   header('Location: is_the_information_correct.php');
  52 }
  53 include_once('header.php');
  54  $qX = "select * from website_text where id = '2'";
  55  $rX = $petition->query($qX);
  56  $dX = mysqli_fetch_array($rX);
  57 ?>
  58 <script>document.title = "MEPS - Enter Information";</script>
  59 <form method='POST'>
  60   <div class='row'>
  61     <div class='col-sm-12' style='height:100px; text-align:center;'><h2><?PHP echo $dX['text_title'];?></h2><p><?PHP echo $dX['text_block'];?></p></div>
  62   </div>
  63   <div class='row'>
  64     <div class='col-sm-4' style='height:50px; text-align:center;'><h3>First Name</h3></div>
  65     <div class='col-sm-4' style='height:50px; text-align:center;'><h3>Last Name</h3></div>
  66     <div class='col-sm-4' style='height:50px; text-align:center;'><h3>Date of Birth</h3></div>
  67   </div>
  68   <div class='row'>
  69     <div class='col-sm-4' style='height:50px; text-align:center;'><input name='web_first_name'></div>
  70     <div class='col-sm-4' style='height:50px; text-align:center;'><input name='web_last_name'></div>
  71     <div class='col-sm-4' style='height:50px; text-align:center;'><input name='DOB' type="date"></div>
  72     </div>
  73   <div class='row'>
  74     <div class='col-sm-4' style='height:50px; text-align:center;'><h3>House Number</h3></div>
  75     <div class='col-sm-4' style='height:50px; text-align:center;'><h3>ZIP Code</h3></div>
  76     <div class='col-sm-4' style='height:50px; text-align:center;'><h3>Phone Number</h3></div>
  77   </div>
  78   <div class='row'>
  79     <div class='col-sm-4' style='height:50px; text-align:center;'><input name='web_house_number'> </div>
  80     <div class='col-sm-4' style='height:50px; text-align:center;'><input name='web_zip_code'> </div>
  81     <div class='col-sm-4' style='height:50px; text-align:center;'><input name='contact_phone'> </div>
  82   </div>
  83   <div class='row'>
  84     <div class='col-sm-12' style='height:50px; text-align:center;'><button type="submit" class="btn btn-success">Next</button></div>
  85   </div>
  86   <div class='row'>
  87     <div class='col-sm-12' style='height:50px; text-align:center;'><button type="reset" class="btn btn-warning">Clear</button></div>
  88   </div>
  89 </form>
  90 <?PHP include_once('footer.php');