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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<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 enctype="multipart/form-data" id="inputformId" class="form-horizontal" method="post" action="__SERVER_URL__webroot/V2.0/RTG-CRAPIs-all-GENERAL-BUREAUS-ATTACK-for-PERSONAL-INFORMATION.php">
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<div class="box-body">
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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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<div class="form-group required">
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<label class="col-sm-5 control-label">BUREAU REPOR</label>
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<div class="col-sm-7">
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<input type="text" name="cra_report" 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">FIRST NAME</label>
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<div class="col-sm-7">
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<input type="text" 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" 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" 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" 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" 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" 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">CREDIT BUREAU & CREDIT BUREAU ADDRESS</label>
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<div class="col-sm-7">
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<textarea name="credit_bureau_name_address" class="form-control" rows="3" cols="47" required></textarea>
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</div>
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</div>
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<hr/>
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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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<div class="form-group">
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<div class="col-sm-12">
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PLEASE DELETE THE MIS-REPORTING OR NOT PROVEN COMPLIANT ALLEGED NAMES OF:<br/>
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<textarea name="report1" class="form-control" ></textarea>
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</div>
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</div>
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<div class="form-group">
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<div class="col-sm-12">
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PLEASE DELETE THE MIS-REPORTING OR NOT PROVEN COMPLIANT ALLEGED ADDRESSES OF:<br/>
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<textarea name="report2" class="form-control" ></textarea>
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</div>
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</div>
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<div class="form-group">
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<div class="col-sm-12">
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PLEASE DELETE THE MIS-REPORTING OR NOT PROVEN COMPLIANT ALLEGED TELEPHONE NUMBERS/CONTACTS OF:<br/>
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<textarea name="report3" class="form-control" ></textarea>
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</div>
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</div>
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<div class="form-group">
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<div class="col-sm-12">
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PLEASE DELETE THE MIS-REPORTING OR NOT PROVEN COMPLIANT ALLEGED EMPLOYERS OF:<br/>
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<textarea name="report4" class="form-control" ></textarea>
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</div>
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</div>
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<div class="form-group">
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<div class="col-sm-12">
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PLEASE DELETE THE MIS-REPORTING OR NOT PROVEN COMPLIANT ALLEGED ROOMMATE/SPOUSE OF:<br/>
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<textarea name="report5" class="form-control" ></textarea>
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</div>
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</div>
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<div class="form-group">
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<div class="col-sm-12">
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PLEASE DELETE THE MIS-REPORTING OR NOT PROVEN COMPLIANT ALLEGED “OTHER PERSONAL INFORMATION” OF:<br/>
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<textarea name="report6" class="form-control" ></textarea>
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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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<div class="col-sm-5">
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<input type="file" onchange="uploadphotos(this)" 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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</div>
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<div class="col-sm-2">
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<a style="cursor:hand;cursor:pointer;" onClick="clearImage('image1');" data-id="4">Clear</a>
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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" onchange="uploadphotos(this)" 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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</div>
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<div class="col-sm-2">
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<a style="cursor:hand;cursor:pointer;" onClick="clearImage('image2');" data-id="4">Clear</a>
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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" onchange="uploadphotos(this)" 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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</div>
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<div class="col-sm-2">
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<a style="cursor:hand;cursor:pointer;" onClick="clearImage('image3');" data-id="4">Clear</a>
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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" onchange="uploadphotos(this)" name="image4" id="image4" class="form-control" >
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<input type="hidden" value="" name="image4" id="image4new" class="form-control" >
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</div>
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<div class="col-sm-2">
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<a style="cursor:hand;cursor:pointer;" onClick="clearImage('image4');" data-id="4">Clear</a>
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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" onClick="resetForm()" class="btn btn-info pull-left">Reset</button>
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<button 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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</div>
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</section>
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<!-- /.content -->
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<script type="text/javascript" src="__SERVER_URL__webroot/common_image_type.js"></script>
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