inital commit
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<!-- Main content -->
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<section class="content">
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<div class="row">
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<!-- right column -->
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<div class="col-md-12">
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<!-- Horizontal Form -->
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<div class="box box-info">
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<div class="box-header with-border">
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<h3 class="box-title"> Enter Your Information Below</h3>
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</div>
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<!-- /.box-header -->
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<!-- form start -->
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<form onsubmit="return getCount()" enctype="multipart/form-data" id="inputformId" class="form-horizontal" method="post" action="__SERVER_URL__webroot/GuestForms/RTG-SAGESTREAM-LETTER-for-FREEZE-REQUEST-1.php">
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<div class="box-body">
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<div class="row">
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<input type="hidden" value="guest_email" name="email" class="form-control">
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<!-- right column -->
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<div class="col-md-10">
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<div class="form-group required">
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<label class="col-sm-5 control-label">FIRST NAME</label>
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<div class="col-sm-7">
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<input type="text" id="first_name" name="first_name" class="form-control" required>
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">LAST NAME</label>
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<div class="col-sm-7">
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<input type="text" id="last_name" name="last_name" class="form-control" required >
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">STREET NO</label>
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<div class="col-sm-7">
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<input type="text" id="street_no" name="street_no" class="form-control" required>
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">STREET NAME</label>
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<div class="col-sm-7">
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<input type="text" id="street_name" name="street_name" class="form-control" required >
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">CITY</label>
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<div class="col-sm-7">
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<input type="text" id="city" name="city" class="form-control" required >
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">STATE</label>
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<div class="col-sm-7">
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<input type="text" id="state" name="state" class="form-control" required >
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">CURRENT SOCIAL SECURITY NUMBER</label>
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<div class="col-sm-7">
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<input type="text" id="social_security_no" name="current_ssn" class="form-control" required >
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">CURRENT DATE OF BIRTH</label>
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<div class="col-sm-7">
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<input type="text" id="birth_date" name="current_dob" class="form-control" required >
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">YOUR LAWFUL SIGNATURE</label>
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<div class="col-sm-7">
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<input type="text" id="sincerely" name="signature_affiant" class="form-control" required >
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</div>
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</div>
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</div>
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</div>
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<div class="row">
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<!-- right column -->
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<div class="col-md-10">
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<hr/>
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<div class="form-group ">
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<label class="col-sm-5 control-label"></label>
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<label class="col-sm-5">Please choose two documents that verify your identity:</label>
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</div>
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<!--for uploading media-->
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<div class="form-group" id="uploadSection" style="display:none;">
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<div class="col-sm-3 col-sm-offset-5">
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<button type="button" class="btn btn-primary" data-toggle="modal" data-target=".media-upload-modal-lg">Upload Media</button>
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<div class="modal fade media-upload-modal-lg" tabindex="-1" role="dialog" aria-labelledby="myLargeModalLabel">
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<div class="modal-dialog modal-lg" role="document">
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<div class="modal-content">
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<div class="modal-header">
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<button type="button" class="close" data-dismiss="modal" aria-label="Close"><span aria-hidden="true">×</span></button>
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<h4 class="modal-title" id="gridSystemModalLabel">Upload Media</h4>
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</div>
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<div class="modal-body" id="uploadMediaSection">
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</div>
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</div>
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</div>
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</div>
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</div>
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</div>
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<div class="form-group ">
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<label class="col-sm-5 control-label">Evidence of my Proof of identification<br/>(PNG, JPG,BMP etc. )</label>
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<input type="hidden" value="" name="clientId" id="clientId" class="form-control" >
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<div class="col-sm-5">
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<input type="file" name="image1" id="image1" class="form-control" >
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<input type="hidden" value="" name="image1" id="image1new" class="form-control" >
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<span class="help-block text-center">
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<img id="image1-old-view" alt="" src="" style="margin-top:5px;width:100px;height:100px;"/>
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</span>
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</div>
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<div class="col-sm-2">
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<label id="label1"><a style="cursor:hand;cursor:pointer;" onClick="clearImage('image1');" data-id="4">Clear</a></label>
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</div>
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</div>
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<div class="form-group ">
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<label class="col-sm-5 control-label">Proof of residence or mailing address<br/>(PNG, JPG,BMP etc. )</label>
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<div class="col-sm-5">
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<input type="file" name="image2" id="image2" class="form-control" >
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<input type="hidden" value="" name="image2" id="image2new" class="form-control" >
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<span class="help-block text-center">
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<img id="image2-old-view" alt="" src="" style="margin-top:5px;width:100px;height:100px;"/>
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</span>
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</div>
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<div class="col-sm-2">
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<label id="label2"> <a style="cursor:hand;cursor:pointer;" onClick="clearImage('image2');" data-id="4">Clear</a></lable>
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</div>
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</div>
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<div class="form-group ">
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<label class="col-sm-5 control-label">Proof of social security number<br/>(PNG, JPG,BMP etc. )</label>
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<div class="col-sm-5">
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<input type="file" name="image3" id="image3" class="form-control" >
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<input type="hidden" value="" name="image3" id="image3new" class="form-control" >
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<span class="help-block text-center">
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<img id="image3-old-view" alt="" src="" style="margin-top:5px;width:100px;height:100px;"/>
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</span>
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</div>
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<div class="col-sm-2">
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<label id="label3"><a style="cursor:hand;cursor:pointer;" onClick="clearImage('image3');" data-id="4">Clear</a></label>
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</div>
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</div>
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<div class="form-group ">
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<label class="col-sm-5 control-label">Your Notarized Letter/form Here(if needed)<br/>(PNG, JPG,BMP etc. )</label>
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<div class="col-sm-5">
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<input type="file" name="image4" id="image4" class="form-control" >
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<input type="hidden" value="" name="image4" id="image5new" class="form-control" >
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<span class="help-block text-center">
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<img id="image5-old-view" alt="" src="" style="margin-top:5px;width:100px;height:100px;"/>
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</span>
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</div>
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<div class="col-sm-2">
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<label id="label5"> <a style="cursor:hand;cursor:pointer;" onClick="clearImage('image4');" data-id="4">Clear</a></label>
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</div>
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</div>
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<hr/>
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<div class="form-group">
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<div class="col-sm-offset-5 col-sm-4">
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<button type="button" id="resetForm" class="btn btn-info pull-left">Reset</button>
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<button id="submit" type="submit" class="btn btn-info pull-right">Generate PDF</button>
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</div>
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</div>
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</div>
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</div>
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</div>
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<!-- /.box-body -->
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<div class="box-footer"></div>
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<!-- /.box-footer -->
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</form>
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</div>
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<!-- /.box -->
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</div>
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<!--/.col (right) -->
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</div>
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<!-- /.row -->
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</section>
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<!-- /.content -->
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<script>
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function getCount() {
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var indiactor = false;
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$.ajax({
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type: 'GET',
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url: '__SERVER_URL__/Guestform/getFormDetail/',
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async: false,
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success: function (data) {
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var json = JSON.parse(data);
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var id = json[0].id;
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var form = 'form_63';
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var count = json[0].form_63;
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if (count < __FORM_COUNTED__) {
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increaseCount(count, id, form);
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indiactor = true;
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} else {
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alert("You have already used your free trial limit.");
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indiactor = false;
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}
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}
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});
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return indiactor;
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}
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function increaseCount(count, id, form) {
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$.ajax({
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type: 'POST',
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url: '__SERVER_URL__/Guestform/increaseCount/',
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data: {count: count, id: id, form: form},
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success: function (data) {
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console.log(data);
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var json = JSON.parse(data);
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alert("You have used "+json.count+" out of __FORM_COUNTED__ limit.");
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}
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});
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}
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</script>
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Reference in New Issue
Block a user