187 lines
12 KiB
HTML
187 lines
12 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 class="form-horizontal" id="inputformId" method="post" enctype="multipart/form-data" action="__SERVER_URL__webroot/Staff/VipRTG-CHP-13-COR-L-4-WAGE-EARNER-BANKRUPTCY-for-STAFF-ONLY-LETTER-4-sent-day-1-with-a-11-by-9-preaddressed-prepaid-envelope.php">
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<div class="box-body">
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<div class="row">
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<input type="hidden" name="form_id" value="43">
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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 required">
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<label class="col-sm-5 control-label">Choose The Credit bureau Your Sending Too</label>
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<div class="col-sm-7">
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<select name="report_file_name" class="form-control" >
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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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<option selected value="3">TransUnion File 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">Credit Bureau Report Number</label>
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<div class="col-sm-7">
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<input type="text" name="experian_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">Your One and Only current First and Last name AND Street NUMBER and Street NAME along with my
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current resident CITY and STATE, ANY OTHER INFORMATION reported I compel you to REMOVE
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IMMEDIATELY as I do NOT AUTHORIZE you nor any entity to retain nor report ANY NOT REQUISITE
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REPORTED INFORMATION or Personal Identifiers that are NOT CURRENT:</label>
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<div class="col-sm-7">
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<textarea name="name_address" id="clientInfo" class="form-control" rows=8 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">Your CHP 13 WAGE EARNER BANKRUPTCY <b>Court and Court with Clerk of Court's address</b>
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EXACTLY how is displayed on my Credit Report(s):</label>
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<div class="col-sm-7">
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<textarea name="records" class="form-control public-record-textarea" rows=10 required ></textarea>
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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-5 control-label">Copy of SS Card<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-5">
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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="image3new" class="form-control" >
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<span class="help-block text-center">
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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('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-5 control-label">Copy of State Photo ID<br/>(PNG, JPG,BMP etc. )</label>
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<div class="col-sm-5">
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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="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('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-5 control-label">Copy of PROOF of your CURRENT and ONLY REQUISITE REPORTED ADDRESS<br/>(PNG, JPG,BMP etc. )</label>
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<div class="col-sm-5">
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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="image2new" class="form-control" >
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<span class="help-block text-center">
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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('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-5 control-label">Your Notarized Letter/form Here(if needed)<br/>(PNG, JPG,BMP etc. )</label>
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<div class="col-sm-5">
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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="image5new" class="form-control" >
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<input type="hidden" value="" name="image5" 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('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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<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
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</button>
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<button type="submit" class="btn btn-info pull-right">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 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>
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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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