From 748021411cc4815a1c4407f87e344c208db642d4 Mon Sep 17 00:00:00 2001 From: Patrick McGuire Date: Fri, 31 Jul 2020 09:41:05 -0400 Subject: [PATCH] Create enter_information_v2.php --- enter_information_v2.php | 161 +++++++++++++++++++++++++++++++++++++++ 1 file changed, 161 insertions(+) create mode 100644 enter_information_v2.php diff --git a/enter_information_v2.php b/enter_information_v2.php new file mode 100644 index 0000000..31cdf3c --- /dev/null +++ b/enter_information_v2.php @@ -0,0 +1,161 @@ + + + + query($qX); + $dX = mysqli_fetch_array($rX); +?> + +
+ +
+

+
+ + +
+

E-Mail for Follow Up*

+
+
+
+ +
+

First Name

+
+
+
+ +
+

Last Name

+
+
+
+ +
+

Date of Birth

+
+
+ +
+ +
+
+
+
+

Phone Number**

+
+
+
+
+

Phone Format

+

443-123-4567

+
+
+
+

Building Number

+
+
+
+
+

House: 321 Here St.

+

Use: 321

+
+
+
+

Apartment: 21 Here St. Apt 1323

+

Use: 21

+
+
+
+

ZIP Code

+
+
+
+
+

ZIP Code Format

+

55555

+
+
+
+
+
+
+
+
+
+
* E-Mail is not required, and will only be used with the petitioners to reach you. It will never be sold.
+
+
+
** PHONE NUMBER IS REQUIRED BY STATE OF MARYLAND. WE WILL NEVER USE YOUR PHONE NUMBER - NEVER CALL - NEVER FOR TEXT MESSAGES.
+
+
+ +