383 lines
22 KiB
HTML
383 lines
22 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 enctype="multipart/form-data" id="inputformId" class="form-horizontal" method="post" action="__SERVER_URL__webroot/V2.0/RTG-med-COLLECTIONS-cra.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 rtg-make-empty-field" 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">Sincerely</label>
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<div class="col-sm-7">
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<input type="text" id="sincerely" name="sincerely" class="form-control" required >
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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 negative-modal-area">
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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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Medical creditor#1:<br/>
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<input type="text" name="creditor1" class="form-control" >
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</div>
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<div class="col-sm-6">
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Account #1 ALLEGED:<br/>
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<input type="text" name="account1" class="form-control" >
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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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Medical creditor#2:<br/>
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<input type="text" name="creditor2" class="form-control" >
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</div>
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<div class="col-sm-6">
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Account #2 ALLEGED:<br/>
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<input type="text" name="account2" class="form-control" >
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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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Medical creditor#3:<br/>
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<input type="text" name="creditor3" class="form-control" >
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</div>
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<div class="col-sm-6">
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Account #3 ALLEGED:<br/>
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<input type="text" name="account3" class="form-control" >
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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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Medical creditor#4:<br/>
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<input type="text" name="creditor4" class="form-control" >
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</div>
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<div class="col-sm-6">
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Account #4 ALLEGED:<br/>
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<input type="text" name="account4" class="form-control" >
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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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Medical creditor#5:<br/>
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<input type="text" name="creditor5" class="form-control" >
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</div>
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<div class="col-sm-6">
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Account #5 ALLEGED:<br/>
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<input type="text" name="account5" class="form-control" >
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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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Medical creditor#6:<br/>
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<input type="text" name="creditor6" class="form-control" >
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</div>
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<div class="col-sm-6">
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Account #6 ALLEGED:<br/>
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<input type="text" name="account6" class="form-control" >
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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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Medical creditor#7:<br/>
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<input type="text" name="creditor7" class="form-control" >
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</div>
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<div class="col-sm-6">
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Account #7 ALLEGED:<br/>
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<input type="text" name="account7" class="form-control" >
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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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Medical creditor#8:<br/>
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<input type="text" name="creditor8" class="form-control" >
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</div>
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<div class="col-sm-6">
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Account #8 ALLEGED:<br/>
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<input type="text" name="account8" class="form-control" >
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</div>
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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-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 State Photo ID<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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<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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<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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<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="image6" id="image6" class="form-control" >
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<input type="hidden" value="" name="image6" id="image6new" 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="image6-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('image6');" 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" 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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