2 if (empty($_COOKIE['signature_status'])){
3 setcookie("signature_status", 'unverified');
5 if (isset($_POST['web_first_name'])){
7 if (isset($_POST['email'])){
8 if ($_POST['email'] != ''){
9 $email = $_POST['email'];
10 setcookie("email", $email);
14 if (isset($_POST['DOB'])){
15 if ($_POST['DOB'] != ''){
17 setcookie("pDOB", $DOB);
21 if (isset($_POST['web_first_name'])){
22 if ($_POST['web_first_name'] != ''){
23 $web_first_name = $_POST['web_first_name'];
24 setcookie("web_first_name", $web_first_name);
28 if (isset($_POST['web_last_name'])){
29 if ($_POST['web_last_name'] != ''){
30 $web_last_name = $_POST['web_last_name'];
31 setcookie("web_last_name", $web_last_name);
34 if(isset($_POST['web_last_name']) && isset($_POST['web_first_name'])){
35 setcookie("web_name", $web_first_name.' '.$web_last_name);
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", $web_house_number);
45 if (isset($_POST['web_zip_code'])){
46 if ($_POST['web_zip_code'] != ''){
47 $web_zip_code = $_POST['web_zip_code'];
48 setcookie("web_zip_code", $web_zip_code);
52 if (isset($_POST['contact_phone'])){
53 if ($_POST['contact_phone'] != ''){
54 $contact_phone = $_POST['contact_phone'];
55 setcookie("pPHONE", $contact_phone);
58 header('Location: is_the_information_correct.php');
60 include_once('header.php');
61 slack_general('Enter Information ('.$_COOKIE['invite'].')','md-petition');
63 <link id
="bsdp-css" href
="files/bootstrap-datepicker3.min.css" rel
="stylesheet">
64 <script src
="files/bootstrap-datepicker.min.js"></script
>
66 $qX = "select * from website_text where id = '2'";
67 $rX = $petition->query($qX);
68 $dX = mysqli_fetch_array($rX);
70 <script
>document
.title
= "MEPS - Enter Information";</script
>
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
>
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
>
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
>
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
>
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('')">
103 var $d = jQuery
.noConflict();
104 $d('.input-group.date').datepicker({
105 format
: "mm/dd/yyyy",
110 <div
class='col-sm-1' style
='text-align:center;'><button type
="submit" class="btn btn-success btn-lg btn-block">↴
</button
></div
>
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
>
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
>
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
>
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
>
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
>
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
>
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
>
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
>
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
>
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
>
157 <div
class='col-sm-10' style
='text-align:center;'>** WE WILL NEVER
USE YOUR PHONE NUMBER
- NEVER CALL
- NEVER
FOR TEXT MESSAGES
.</div
>
161 <?PHP
include_once('footer.php');