197 lines
9.7 KiB
HTML
197 lines
9.7 KiB
HTML
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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 class="form-horizontal" id="inputformId" method="post" enctype="multipart/form-data" action="__SERVER_URL__Staff/STAFF-M2CA-Method-SUPER-609-wave-1-BUREAUS.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">Choose The Credit bureau Your Sending Too</label>
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<div class="col-sm-7">
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<select name="report_file_name" class="form-control" >
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<option value="1">Experian Report</option>
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<option value="2">Equifax Confirmation Report</option>
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<option selected value="3">TransUnion File Report</option>
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<option value="4">INNOVIS</option>
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<option value="5">LEXISNEXIS</option>
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</select>
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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 Report Number</label>
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<div class="col-sm-7">
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<input type="text" name="experian_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"> QUESTIONABLE and or NOT COMPLIANT, UNTRUE, INCORRECT, INCOMPLETE, or else wise infringing item(s) in question is(are) as follows:</label>
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<div class="col-sm-7">
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<textarea name="input_value" class="form-control" rows="3" cols="47" required></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">Copy of SS Card<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">Copy of State Photo ID<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">Copy of PROOF of your CURRENT and ONLY REQUISITE REPORTED 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="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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<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
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</button>
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<button type="submit" class="btn btn-info pull-right">Generate
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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 type="text/javascript" src="../common_image_type.js"></script> |