142 lines
7.5 KiB
HTML
142 lines
7.5 KiB
HTML
|
|
|
|
<!-- Main content -->
|
|
<section class="content">
|
|
<div class="row">
|
|
|
|
<!-- right column -->
|
|
<div class="col-md-12">
|
|
<!-- Horizontal Form -->
|
|
<div class="box box-info">
|
|
<div class="box-header with-border">
|
|
<h3 class="box-title"> Enter Your Information Below</h3>
|
|
</div>
|
|
<!-- /.box-header -->
|
|
<!-- form start -->
|
|
<form class="form-horizontal" id="inputformId" method="post" enctype="multipart/form-data" action="__SERVER_URL__webroot/Staff/VipRTG-CH7-L4-to-COR-Bankrupties-DESIGNED-for-STAFF-USE-ONLY-and-for-only-one-chapter-7-per-letter-to-be-mailed-faxed-and-uploaded-on-day-1.php">
|
|
<div class="box-body">
|
|
<div class="row">
|
|
|
|
<!-- right column -->
|
|
<div class="col-md-10">
|
|
<div class="form-group">
|
|
<label class="col-sm-5 control-label">PLEASE SELECT</label>
|
|
<div class="col-sm-7">
|
|
<select id="client-contact-id" name="select" class="form-control">
|
|
</select>
|
|
</div>
|
|
</div>
|
|
|
|
<!-- <div class="form-group required">
|
|
<label class="col-sm-5 control-label">Choose The Credit bureau Your Sending Too</label>
|
|
|
|
<div class="col-sm-7">
|
|
<select name="report_file_name" class="form-control" >
|
|
<option value="1">Experian Report</option>
|
|
<option value="2">Equifax Confirmation Report</option>
|
|
<option selected value="3">TransUnion File Report</option>
|
|
|
|
</select>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group required">
|
|
<label class="col-sm-5 control-label">Credit Bureau Report Number</label>
|
|
|
|
<div class="col-sm-7">
|
|
<input type="text" name="experian_report" class="form-control" required >
|
|
</div>
|
|
</div> -->
|
|
<div class="form-group required">
|
|
<input type="hidden" value="" name="clientId" id="clientId" class="form-control" >
|
|
<label class="col-sm-5 control-label">Your One and Only current First and Last name AND Street NUMBER and Street NAME along with my
|
|
current resident CITY and STATE, ANY OTHER INFORMATION reported I compel you to REMOVE
|
|
IMMEDIATELY as I do NOT AUTHORIZE you nor any entity to retain nor report ANY NOT REQUISITE
|
|
REPORTED INFORMATION or Personal Identifiers that are NOT CURRENT:</label>
|
|
|
|
<div class="col-sm-7">
|
|
<textarea name="name_address" id="clientInfo" class="form-control" rows=8 required ></textarea>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group required">
|
|
<label class="col-sm-5 control-label">Your Court and Court with Clerk of Court's address EXACTLY how is displayed on my Credit Report(s):</label>
|
|
|
|
<div class="col-sm-7">
|
|
<textarea name="records" class="form-control public-record-textarea" rows=10 required ></textarea>
|
|
</div>
|
|
</div>
|
|
|
|
<!-- <div class="form-group ">
|
|
<label class="col-sm-5 control-label">Copy of SS Card<br/>(PNG, JPG,BMP etc. )</label>
|
|
|
|
<div class="col-sm-5">
|
|
<input type="file" name="image1" id="image1" class="form-control" >
|
|
</div>
|
|
<div class="col-sm-2">
|
|
<a style="cursor:hand;cursor:pointer;" onClick="clearImage('image1');" data-id="4">Clear</a>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group ">
|
|
<label class="col-sm-5 control-label">Copy of State Photo ID<br/>(PNG, JPG,BMP etc. )</label>
|
|
|
|
<div class="col-sm-5">
|
|
<input type="file" name="image2" id="image2" class="form-control" >
|
|
</div>
|
|
<div class="col-sm-2">
|
|
<a style="cursor:hand;cursor:pointer;" onClick="clearImage('image2');" data-id="4">Clear</a>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group ">
|
|
<label class="col-sm-5 control-label">Copy of PROOF of your CURRENT and ONLY REQUISITE REPORTED ADDRESS<br/>(PNG, JPG,BMP etc. )</label>
|
|
|
|
<div class="col-sm-5">
|
|
<input type="file" name="image3" id="image3" class="form-control" >
|
|
</div>
|
|
<div class="col-sm-2">
|
|
<a style="cursor:hand;cursor:pointer;" onClick="clearImage('image3');" data-id="4">Clear</a>
|
|
</div>
|
|
</div> -->
|
|
|
|
|
|
|
|
<div class="form-group">
|
|
|
|
|
|
|
|
<div class="col-sm-offset-5 col-sm-4">
|
|
|
|
<button type="button" id="resetForm" class="btn btn-info pull-left">Reset
|
|
</button>
|
|
|
|
<button type="submit" class="btn btn-info pull-right">Generate
|
|
PDF</button>
|
|
</div>
|
|
</div>
|
|
|
|
</div>
|
|
<div class="col-md-2" style="padding-left:0px;padding-top: 3px;">
|
|
<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="">
|
|
</div>
|
|
</div>
|
|
|
|
</div>
|
|
<!-- /.box-body -->
|
|
<div class="box-footer"></div>
|
|
<!-- /.box-footer -->
|
|
</form>
|
|
</div>
|
|
<!-- /.box -->
|
|
|
|
</div>
|
|
<!--/.col (right) -->
|
|
</div>
|
|
<!-- /.row -->
|
|
|
|
|
|
</section>
|
|
<!-- /.content -->
|