440 lines
28 KiB
HTML
440 lines
28 KiB
HTML
<script src="__SERVER_URL__webroot/rtgv3/js/select2.full.min.js"></script>
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<script src='__SERVER_URL__webroot/admin_lte/plugins/datepicker/bootstrap-datepicker.js'></script>
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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 enctype="multipart/form-data" id="inputformId" class="form-horizontal" method="post" action="__SERVER_URL__webroot/V2.0/RTG-SCRM-cra-5-attack-letter.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">
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<label class="col-sm-5 control-label">PLEASE SELECT</label>
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<div class="col-sm-7">
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<select id="client-contact-id" name="select" class="form-control">
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</select>
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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">CREDIT REPORT COMPANY NAME</label>
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<div class="col-sm-7">
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<select name="report_file_name" id="report_file_name" class="form-control" >
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<option value="0">Please Select</option>
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<option value="3">TransUnion File Report</option>
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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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</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">CRA REPORT</label>
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<div class="col-sm-7">
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<input type="text" id="cra_report" 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" 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" id="credit_bureau_field">
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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" id="credit_bureau_address" 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 required">
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<label class="col-sm-5 control-label">DATE OF BIRTH</label>
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<div class="col-sm-7">
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<input type="text" id="birth_date" name="date_of_birth" 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">SSN</label>
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<div class="col-sm-7">
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<input type="text" id="social_security_no" name="ssn" class="form-control" style="margin-bottom: -20px;" required >
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<span style="float: left;">
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<label class="help-block-ssnLenght" style="color:red;" > </label>
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</span>
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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">ACCOUNT ASPECTS</label>
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<div class="col-sm-7">
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<select name="account_aspects[]" multiple="multiple" id="account_aspects" data-placeholder="Please Select" class="form-control select2" >
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<option value="DATE REPORTED">DATE REPORTED</option>
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<option value="STATUS DATE">STATUS DATE</option>
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<option value="BALANCE DATE">BALANCE DATE</option>
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<option value="BALANCE AMOUNT">BALANCE AMOUNT</option>
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<option value="ACCOUNT STATUS">ACCOUNT STATUS</option>
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<option value="ACCOUNT TYPE">ACCOUNT TYPE</option>
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<option value="ACCOUNT OWNERSHIP/RESPONSIBILITY">ACCOUNT OWNERSHIP/RESPONSIBILITY</option>
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<option value="ACCOUNT CURRENT BALANCE">ACCOUNT CURRENT BALANCE</option>
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<option value="ACCOUNT HIGH LIMIT">ACCOUNT HIGH LIMIT</option>
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<option value="ACCOUNT TERMS">ACCOUNT TERMS</option>
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<option value="ACCOUNT PAYMENT HISTORY GRID">ACCOUNT PAYMENT HISTORY GRID</option>
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<option value="DATE FILED">DATE FILED</option>
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<option value="DATE DISMISSED">DATE DISMISSED</option>
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<option value="DATE DISCHARGED">DATE DISCHARGED</option>
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<option value="LIABILITY LIMIT">LIABILITY LIMIT</option>
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<option value="ASSET AMOUNT">ASSET AMOUNT</option>
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<option value="DATE OF FIRST DELINQUENCY (DOFD)">DATE OF FIRST DELINQUENCY (DOFD)</option>
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<option value="DATE FIRST MAJOR DELINQUENCY (DFMD)">DATE FIRST MAJOR DELINQUENCY (DFMD)</option>
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<option value="ACCOUNT 30/60/90 STATUS">ACCOUNT 30/60/90 STATUS</option>
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<option value="ACCOUNT COMMENTS">ACCOUNT COMMENTS</option>
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<option value="MONTHLY PAYMENT AMOUNT">MONTHLY PAYMENT AMOUNT</option>
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<option value="PAST DUE AMOUNT">PAST DUE AMOUNT</option>
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<option value="REFERENCE /FILE NUMBER">REFERENCE /FILE NUMBER</option>
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<option value="DATE OF ALLEGED INQUIRY">DATE OF ALLEGED INQUIRY</option>
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</select>
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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">ACCOUNT DEROGATORY</label>
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<div class="col-sm-7">
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<select name="account_derogatory" id="account_derogatory" class="form-control" >
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<option value="0">Please Select</option>
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<option value="INQUIRY">INQUIRY</option>
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<option value="LATE PAYMENT">LATE PAYMENT</option>
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<option value="STUDENT LOAN">STUDENT LOAN</option>
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<option value="MEDICAL debt COLLECTION">MEDICAL debt COLLECTION</option>
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<option value="NON-MEDICAL REGULAR debt COLLECTION">NON-MEDICAL REGULAR debt COLLECTION</option>
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<option value="CHARGE-OFF/WRITE-OFF">CHARGE-OFF/WRITE-OFF</option>
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<option value="JUDGMENT">JUDGMENT</option>
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<option value="BANKRUPTCY">BANKRUPTCY</option>
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<option value="REPOSSESSION">REPOSSESSION</option>
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<option value="FORECLOSURE">FORECLOSURE</option>
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<option value="SHORT SALE">SHORT SALE</option>
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<option value="TAX LIEN">TAX LIEN</option>
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<option value="ALIMONY ARREARS">ALIMONY ARREARS</option>
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<option value="CHILD SUPPORT ARREARS">CHILD SUPPORT ARREARS</option>
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<option value="TITLE LOAN DEFAULT (TLD)">TITLE LOAN DEFAULT (TLD)</option>
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<option value="PAYDAY LOAN (PDL)">PAYDAY LOAN (PDL)</option>
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<option value="AUTHORIZED USER ACCOUNT (AU)">AUTHORIZED USER ACCOUNT (AU)</option>
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<option value="TERMINATED OWNERSHIP">TERMINATED OWNERSHIP</option>
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<option value="OTHER">OTHER</option>
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</select>
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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 class="col-md-2" style="padding-left:0px;padding-top: 3px;">
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<img style="margin-left:0px; height:30px; width:30px;" id="client-contact-loading-img" class="rtg-loading-img" src="__SERVER_URL__webroot/loading/loading.gif" alt="">
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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-6">
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Report Data#1:<br/>
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<textarea name="report-data1" rows="3" class="form-control" ></textarea>
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</div>
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<div class="col-sm-6">
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Report Image#1:<br/>
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<input type="file" onchange="uploadphotos(this)" name="report-image1" id="report-image1" class="form-control" >
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<input type="hidden" value="" name="report-image1" id="report-image1new" class="form-control" >
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<div class="col-sm-2">
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<label><a style="cursor:hand;cursor:pointer;" onClick="clearImage('report-image1');" data-id="4">Clear</a></label>
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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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<div class="col-sm-6">
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Report Data#2:<br/>
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<textarea name="report-data2" rows="3" class="form-control" ></textarea>
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</div>
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<div class="col-sm-6">
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Report Image#2:<br/>
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<input type="file" onchange="uploadphotos(this)" name="report-image2" id="report-image2" class="form-control" >
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<input type="hidden" value="" name="report-image2" id="report-image2new" class="form-control" >
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<div class="col-sm-2">
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<label><a style="cursor:hand;cursor:pointer;" onClick="clearImage('report-image2');" data-id="4">Clear</a></label>
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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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<div class="col-sm-6">
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Report Data#3:<br/>
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<textarea name="report-data3" rows="3" class="form-control" ></textarea>
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</div>
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<div class="col-sm-6">
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Report Image#3:<br/>
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<input type="file" onchange="uploadphotos(this)" name="report-image3" id="report-image3" class="form-control" >
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<input type="hidden" value="" name="report-image3" id="report-image3new" class="form-control" >
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<div class="col-sm-2">
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<label><a style="cursor:hand;cursor:pointer;" onClick="clearImage('report-image3');" data-id="4">Clear</a></label>
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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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<div class="col-sm-6">
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Report Data#4:<br/>
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<textarea name="report-data4" rows="3" class="form-control" ></textarea>
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</div>
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<div class="col-sm-6">
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Report Image#4:<br/>
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<input type="file" onchange="uploadphotos(this)" name="report-image4" id="report-image4" class="form-control" >
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<input type="hidden" value="" name="report-image4" id="report-image4new" class="form-control" >
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<div class="col-sm-2">
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<label><a style="cursor:hand;cursor:pointer;" onClick="clearImage('report-image4');" data-id="4">Clear</a></label>
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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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<div class="col-sm-6">
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Report Data#5:<br/>
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<textarea name="report-data5" rows="3" class="form-control" ></textarea>
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</div>
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<div class="col-sm-6">
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Report Image#5:<br/>
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<input type="file" onchange="uploadphotos(this)" name="report-image5" id="report-image5" class="form-control" >
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<input type="hidden" value="" name="report-image5" id="report-image5new" class="form-control" >
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<div class="col-sm-2">
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<label><a style="cursor:hand;cursor:pointer;" onClick="clearImage('report-image5');" data-id="4">Clear</a></label>
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</div>
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</div>
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</div>
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<br><br>
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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-6 control-label">Evidence of your 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-4">
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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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<span class="help-block text-center">
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<!--<input name="image1" id="image1-old" type="hidden" class="form-control">-->
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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-6 control-label">Proof of residence or mailing address<br/>(PNG, JPG,BMP etc. )</label>
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<div class="col-sm-4">
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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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<span class="help-block text-center">
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<!--<input name="image2" id="image2-old" type="hidden" class="form-control">-->
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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></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-6 control-label">Proof of social security number<br/>(PNG, JPG,BMP etc. )</label>
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<div class="col-sm-4">
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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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<span class="help-block text-center">
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<!--<input name="image3" value="" id="image3-old" type="hidden" class="form-control">-->
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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-6 control-label">Copy of COLLECTION/CHARGE OFF item(s) under challenge as reported on your credit reporting agency’s reports.<br/>(PNG, JPG,BMP etc. )</label>
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<div class="col-sm-4">
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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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<span class="help-block text-center">
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<!--<input name="image4" id="image4-old" type="hidden" class="form-control">-->
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<img id="image4-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="label4"><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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<div class="form-group ">
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<label class="col-sm-6 control-label">Your Notarized Letter/form Here(if needed)<br/>(PNG, JPG,BMP etc. )</label>
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<div class="col-sm-4">
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<input type="file" onchange="uploadphotos(this)" name="image5" id="image5" class="form-control" >
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<input type="hidden" value="" name="image5" id="image5new" class="form-control" >
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<span class="help-block text-center">
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<!--<input name="image5" id="image5-old" type="hidden" class="form-control">-->
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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('image5');" 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 type="submit" id="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>
|
||
<!-- /.content -->
|
||
<script>
|
||
//$("#date_of_birth").datepicker({autoclose: true,todayHighlight: true, format: 'yyyy-mm-dd'});
|
||
$('.select2').select2();
|
||
$('#submit').click(function(e){
|
||
var ssnLenght = $('#social_security_no').val().length;
|
||
if(ssnLenght !== 4){
|
||
e.preventDefault();
|
||
$('#social_security_no').css({'margin-bottom':''});
|
||
$('label.help-block-ssnLenght').text('Please enter last 4digit of SSN');
|
||
}
|
||
});
|
||
|
||
</script>
|
||
<script type="text/javascript" src="__SERVER_URL__webroot/common_script_file.js?1.0.1"></script>
|
||
<script type="text/javascript" src="__SERVER_URL__webroot/common_image_type.js"></script>
|