322 lines
11 KiB
HTML
322 lines
11 KiB
HTML
<!DOCTYPE html>
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<html>
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<head>
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<meta charset="utf-8">
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<meta http-equiv="X-UA-Compatible" content="IE=edge">
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<title>RTG-med-COLLECTIONS-cra</title>
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<!-- Tell the browser to be responsive to screen width -->
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<meta
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content="width=device-width, initial-scale=1, maximum-scale=1, user-scalable=no"
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name="viewport">
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<!-- Bootstrap 3.3.6 -->
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<link rel="stylesheet" href="http://cloud-height.com/RTG/bootstrap/css/bootstrap.min.css">
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<!-- Font Awesome -->
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<link rel="stylesheet"
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href="https://cdnjs.cloudflare.com/ajax/libs/font-awesome/4.5.0/css/font-awesome.min.css">
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<!-- Ionicons -->
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<link rel="stylesheet"
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href="https://cdnjs.cloudflare.com/ajax/libs/ionicons/2.0.1/css/ionicons.min.css">
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<!-- Theme style -->
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<link rel="stylesheet" href="http://cloud-height.com/RTG/dist/css/AdminLTE.min.css">
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<!-- AdminLTE Skins. Choose a skin from the css/skins
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folder instead of downloading all of them to reduce the load. -->
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<link rel="stylesheet" href="http://cloud-height.com/RTG/dist/css/skins/_all-skins.min.css">
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<!-- HTML5 Shim and Respond.js IE8 support of HTML5 elements and media queries -->
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<!-- WARNING: Respond.js doesn't work if you view the page via file:// -->
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<!--[if lt IE 9]>
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<script src="https://oss.maxcdn.com/html5shiv/3.7.3/html5shiv.min.js"></script>
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<script src="https://oss.maxcdn.com/respond/1.4.2/respond.min.js"></script>
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<![endif]-->
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<style>
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.form-group.required .control-label:before{
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color: red;
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content: "*";
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position: absolute;
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margin-left: -7px;
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}
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</style>
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</head>
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<body class="hold-transition skin-blue sidebar-mini">
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<div class="wrapper" >
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<!-- Content Wrapper. Contains page content -->
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<div class="content-wrapper">
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<!-- Content Header (Page header) -->
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<section class="content-header">
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<h1>R.T.G M.2.M. Letter generator by M.2.C Academy - V1.0</h1>
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<ol class="breadcrumb">
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<li><a href="#"><i class="fa fa-dashboard"></i> Home</a></li>
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<li class="active">RTG-med-COLLECTIONS-cra</li>
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</ol>
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</section>
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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" method="post" action="http://cloud-height.com/RTG/V1.0/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-7">
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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" 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" 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">PERSONAL TRACKING NUMBER(20 Digit)</label>
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<div class="col-sm-7">
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<input type="text" name="personal_tracking_number" class="form-control" maxlength="20" 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">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" 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">Sincerely</label>
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<div class="col-sm-7">
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<input type="text" 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>
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<div class="row">
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<!-- right column -->
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<div class="col-md-7">
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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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<hr/>
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<div class="form-group">
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<div class="col-sm-offset-5 col-sm-7">
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<button type="submit" class="btn btn-info pull-left">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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</div>
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<!-- /.content-wrapper -->
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<footer class="main-footer">
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<strong>Copyright © 2019 <a href="#" >R.T.G M.2.M. Letter generator by M.2.C Academy - V1.0</a>.
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</strong> All rights reserved.
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</footer>
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<!-- Add the sidebar's background. This div must be placed
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immediately after the control sidebar -->
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<div class="control-sidebar-bg"></div>
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</div>
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<!-- ./wrapper -->
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<!-- jQuery 2.2.0 -->
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<script src="http://cloud-height.com/RTG/plugins/jQuery/jQuery-2.2.0.min.js"></script>
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<!-- Bootstrap 3.3.6 -->
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<script src="http://cloud-height.com/RTG/bootstrap/js/bootstrap.min.js"></script>
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<!-- FastClick -->
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<script src="http://cloud-height.com/RTG/plugins/fastclick/fastclick.js"></script>
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<!-- AdminLTE App -->
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<script src="http://cloud-height.com/RTG/dist/js/app.min.js"></script>
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<!-- AdminLTE for demo purposes -->
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<script src="http://cloud-height.com/RTG/dist/js/demo.js"></script>
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</body>
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</html> |