255 lines
14 KiB
HTML
255 lines
14 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 enctype="multipart/form-data" id="inputformId" class="form-horizontal" method="post" action="__SERVER_URL__webroot/V2.0/RTG-SAGESTREAM-LETTER-for-FREEZE-REQUEST-1.php">
|
|
<div class="box-body">
|
|
<div class="row">
|
|
<input type="hidden" value="63" name="form_id" class="form-control">
|
|
<!-- 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">FIRST NAME</label>
|
|
<div class="col-sm-7">
|
|
<input type="text" id="first_name" name="first_name" class="form-control" required>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group required">
|
|
<label class="col-sm-5 control-label">LAST NAME</label>
|
|
<div class="col-sm-7">
|
|
<input type="text" id="last_name" name="last_name" class="form-control" required >
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group required">
|
|
<label class="col-sm-5 control-label">STREET NO</label>
|
|
<div class="col-sm-7">
|
|
<input type="text" id="street_no" name="street_no" class="form-control" required>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group required">
|
|
<label class="col-sm-5 control-label">STREET NAME</label>
|
|
<div class="col-sm-7">
|
|
<input type="text" id="street_name" name="street_name" class="form-control" required >
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group required">
|
|
<label class="col-sm-5 control-label">CITY</label>
|
|
<div class="col-sm-7">
|
|
<input type="text" id="city" name="city" class="form-control" required >
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group required">
|
|
<label class="col-sm-5 control-label">STATE</label>
|
|
<div class="col-sm-7">
|
|
<input type="text" id="state" name="state" class="form-control" required >
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group required">
|
|
<label class="col-sm-5 control-label">CURRENT SOCIAL SECURITY NUMBER</label>
|
|
<div class="col-sm-7">
|
|
<input type="text" id="social_security_no" name="current_ssn" class="form-control" required >
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group required">
|
|
<label class="col-sm-5 control-label">CURRENT DATE OF BIRTH</label>
|
|
<div class="col-sm-7">
|
|
<input type="text" id="birth_date" name="current_dob" class="form-control" required >
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group required">
|
|
<label class="col-sm-5 control-label">YOUR LAWFUL SIGNATURE</label>
|
|
<div class="col-sm-7">
|
|
<input type="text" id="sincerely" name="signature_affiant" class="form-control" required >
|
|
</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 class="row">
|
|
|
|
<!-- right column -->
|
|
<div class="col-md-10">
|
|
<hr/>
|
|
<div class="form-group ">
|
|
<label class="col-sm-5 control-label"></label>
|
|
<label class="col-sm-5">Please choose two documents that verify your identity:</label>
|
|
</div>
|
|
|
|
<!--for uploading media-->
|
|
<div class="form-group" id="uploadSection" style="display:none;">
|
|
<div class="col-sm-3 col-sm-offset-5">
|
|
<button type="button" class="btn btn-primary" data-toggle="modal" data-target=".media-upload-modal-lg">Upload Media</button>
|
|
<div class="modal fade media-upload-modal-lg" tabindex="-1" role="dialog" aria-labelledby="myLargeModalLabel">
|
|
<div class="modal-dialog modal-lg" role="document">
|
|
<div class="modal-content">
|
|
<div class="modal-header">
|
|
<button type="button" class="close" data-dismiss="modal" aria-label="Close"><span aria-hidden="true">×</span></button>
|
|
<h4 class="modal-title" id="gridSystemModalLabel">Upload Media</h4>
|
|
</div>
|
|
<div class="modal-body" id="uploadMediaSection">
|
|
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group ">
|
|
|
|
<label class="col-sm-5 control-label">Evidence of my Proof of identification<br/>(PNG, JPG,BMP etc. )</label>
|
|
<input type="hidden" value="" name="clientId" id="clientId" class="form-control" >
|
|
<div class="col-sm-5">
|
|
<input type="file" onchange="uploadphotos(this)" name="image1" id="image1" class="form-control" >
|
|
<input type="hidden" value="" name="image1" id="image1new" class="form-control" >
|
|
<span class="help-block text-center">
|
|
<img id="image1-old-view" alt="" src="" style="margin-top:5px;width:100px;height:100px;"/>
|
|
</span>
|
|
</div>
|
|
<div class="col-sm-2">
|
|
<label id="label1"><a style="cursor:hand;cursor:pointer;" onClick="clearImage('image1');" data-id="4">Clear</a></label>
|
|
</div>
|
|
|
|
</div>
|
|
|
|
|
|
<div class="form-group ">
|
|
|
|
<label class="col-sm-5 control-label">Proof of residence or mailing address<br/>(PNG, JPG,BMP etc. )</label>
|
|
|
|
<div class="col-sm-5">
|
|
<input type="file" onchange="uploadphotos(this)" name="image2" id="image2" class="form-control" >
|
|
<input type="hidden" value="" name="image2" id="image2new" class="form-control" >
|
|
<span class="help-block text-center">
|
|
<img id="image2-old-view" alt="" src="" style="margin-top:5px;width:100px;height:100px;"/>
|
|
</span>
|
|
</div>
|
|
<div class="col-sm-2">
|
|
<label id="label2"> <a style="cursor:hand;cursor:pointer;" onClick="clearImage('image2');" data-id="4">Clear</a></label>
|
|
</div>
|
|
|
|
</div>
|
|
|
|
|
|
|
|
<div class="form-group ">
|
|
|
|
<label class="col-sm-5 control-label">Proof of social security number<br/>(PNG, JPG,BMP etc. )</label>
|
|
|
|
<div class="col-sm-5">
|
|
<input type="file" onchange="uploadphotos(this)" name="image3" id="image3" class="form-control" >
|
|
<input type="hidden" value="" name="image3" id="image3new" class="form-control" >
|
|
<span class="help-block text-center">
|
|
<img id="image3-old-view" alt="" src="" style="margin-top:5px;width:100px;height:100px;"/>
|
|
</span>
|
|
</div>
|
|
<div class="col-sm-2">
|
|
<label id="label3"><a style="cursor:hand;cursor:pointer;" onClick="clearImage('image3');" data-id="4">Clear</a></label>
|
|
</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" onchange="uploadphotos(this)" name="image4" id="image4" class="form-control" >
|
|
<input type="hidden" value="" name="image4" id="image4new" class="form-control" >
|
|
<span class="help-block text-center">
|
|
<img id="image4-old-view" alt="" src="" style="margin-top:5px;width:100px;height:100px;"/>
|
|
</span>
|
|
</div>
|
|
<div class="col-sm-2">
|
|
<label id="label4"><a style="cursor:hand;cursor:pointer;" onClick="clearImage('image4');" data-id="4">Clear</a></label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group ">
|
|
<label class="col-sm-5 control-label">Your Notarized Letter/form Here(if needed)<br/>(PNG, JPG,BMP etc. )</label>
|
|
|
|
<div class="col-sm-5">
|
|
<input type="file" onchange="uploadphotos(this)" name="image5" id="image5" class="form-control" >
|
|
<input type="hidden" value="" name="image5" id="image5new" class="form-control" >
|
|
<span class="help-block text-center">
|
|
<img id="image5-old-view" alt="" src="" style="margin-top:5px;width:100px;height:100px;"/>
|
|
</span>
|
|
</div>
|
|
<div class="col-sm-2">
|
|
<label id="label5"><a style="cursor:hand;cursor:pointer;" onClick="clearImage('image5');" data-id="4">Clear</a></label>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
|
|
|
|
<hr/>
|
|
|
|
|
|
|
|
<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>
|
|
|
|
|
|
|
|
|
|
</div>
|
|
<!-- /.box-body -->
|
|
<div class="box-footer"></div>
|
|
<!-- /.box-footer -->
|
|
</form>
|
|
</div>
|
|
<!-- /.box -->
|
|
|
|
</div>
|
|
<!--/.col (right) -->
|
|
</div>
|
|
<!-- /.row -->
|
|
|
|
|
|
</section>
|
|
<!-- /.content -->
|