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<form method="post" id="form3Aedit" class="needs-validation" novalidate> <input type="hidden" name="id3a" id="id3a"> <div class="row mt-3"> <div class="col-lg-4"> <div class="mb-1 position-relative" id="3adateInputpickeredit"> <label class="form-label">Date</label> <input type="text" data-date-autoclose="true" class="form-control" id="3adateedit" name="3adateedit" data-provide="datepicker" data-date-format="MM dd, yyyy" data-date-container="#3adateInputpickeredit" required> </div> </div> <div class="col-lg-4"> <div class="mb-1"> <label for="3apagenumedit" class="form-label">Page Number</label> <input type="number" name="3apagenumedit" id="3apagenumedit" class="form-control"> </div> </div> <div class="col-lg-4"> <div class="mb-1"> <label for="3abooknumedit" class="form-label">Book Number</label> <input type="number" name="3abooknumedit" id="3abooknumedit" class="form-control"> </div> </div> </div> <div class="row"> <div class="col-lg-6"> <div class="mb-1"> <label for="3agroomnameedit" class="form-label">Groom Name</label> <input type="text" name="3agroomnameedit" id="3agroomnameedit" class="form-control"> </div> </div> <div class="col-lg-6"> <div class="mb-1"> <label for="3abridenameedit" class="form-label">Bride Name</label> <input type="text" name="3abridenameedit" id="3abridenameedit" class="form-control"> </div> </div> </div> <div class="row"> <div class="col-lg-6"> <div class="mb-1"> <label for="3agroomageedit" class="form-label">Groom Age</label> <input type="text" name="3agroomageedit" id="3agroomageedit" class="form-control"> </div> </div> <div class="col-lg-6"> <div class="mb-1"> <label for="3abrideageedit" class="form-label">Bride Age</label> <input type="text" name="3abrideageedit" id="3abrideageedit" class="form-control"> </div> </div> </div> <div class="row"> <div class="col-lg-6"> <div class="mb-1"> <label for="3agroomcitizenedit" class="form-label">Groom Citizenship</label> <input type="text" name="3agroomcitizenedit" id="3agroomcitizenedit" class="form-control"> </div> </div> <div class="col-lg-6"> <div class="mb-1"> <label for="simpleinput" class="form-label">Bride Citizenship</label> <input type="text" name="3abridecitizenedit" id="3abridecitizenedit" class="form-control"> </div> </div> </div> <div class="row"> <div class="col-lg-6"> <div class="mb-1"> <label for="simpleinput" class="form-label">Groom Civil Status</label> <input type="text" name="3agroomciviledit" id="3agroomciviledit" class="form-control"> </div> </div> <div class="col-lg-6"> <div class="mb-1"> <label for="simpleinput" class="form-label">Bride Civil Status</label> <input type="text" name="3abrideciviledit" id="3abrideciviledit" class="form-control"> </div> </div> </div> <div class="row"> <div class="col-lg-6"> <div class="mb-1"> <label for="simpleinput" class="form-label">Groom's Mother</label> <input type="text" name="3agroommotheredit" id="3agroommotheredit" class="form-control"> </div> </div> <div class="col-lg-6"> <div class="mb-1"> <label for="simpleinput" class="form-label">Bride's Mother</label> <input type="text" name="3abridemotheredit" id="3abridemotheredit" class="form-control"> </div> </div> </div> <div class="row"> <div class="col-lg-6"> <div class="mb-1"> <label for="simpleinput" class="form-label">Groom's Father</label> <input type="text" name="3agroomfatheredit" id="3agroomfatheredit" class="form-control"> </div> </div> <div class="col-lg-6"> <div class="mb-1"> <label for="simpleinput" class="form-label">Bride's Father</label> <input type="text" name="3abridefatheredit" id="3abridefatheredit" class="form-control"> </div> </div> </div> <div class="row"> <div class="col-lg-6"> <div class="mb-1"> <label for="simpleinput" class="form-label">Registry Number</label> <input type="text" name="3aregistrynumedit" id="3aregistrynumedit" class="form-control"> </div> </div> <div class="col-lg-6"> <div class="mb-1 position-relative" id="3adateInputpickerregedit"> <label class="form-label">Date of Registration</label> <input type="text" data-date-autoclose="true" class="form-control" id="3adateregedit" name="3adateregedit" data-provide="datepicker" data-date-format="MM dd, yyyy" data-date-container="#3adateInputpickerregedit" required> </div> </div> </div> <div class="row"> <div class="col-lg-6"> <div class="mb-1 position-relative" id="3adateInputpickermaredit"> <label class="form-label">Date of Marriage</label> <input type="text" data-date-autoclose="true" class="form-control" id="3adatemarriageedit" name="3adatemarriageedit" data-provide="datepicker" data-date-format="MM dd, yyyy" data-date-container="#3adateInputpickermaredit" required> </div> </div> <div class="col-lg-6"> <div class="mb-1"> <label for="simpleinput" class="form-label">Place of Marriage</label> <input type="text" name="3aplacemarriageedit" id="3aplacemarriageedit" class="form-control"> </div> </div> </div> <!-- new --> <div class="row justify-content-center"> <div class="col-lg-6"> <div class="mb-1"> <label for="3aissued" class="form-label">Issued To</label> <input type="text" id="3aissuededit" name="3aissuededit" onchange="handleChange()" class="form-control capslockview" required> </div> </div> </div> <div class="row justify-content-center"> <div class="col-md-10"> <div class="mb-3"> <label for="3aremarks" class="form-label">Remarks</label> <textarea class="form-control" id="3aremarksedit" name="3aremarksedit" rows="3"></textarea> </div> </div> </div> <div class="row"> <div class="col-lg-4"> <div class="mb-1"> <label for="amountPaidInput3a" class="form-label">Amount Paid</label> <input type="text" id="amountPaidInput3aedit" name="amountPaidInput3aedit" class="form-control" required> </div> </div> <div class="col-lg-4"> <div class="mb-1"> <label for="3aorNumber" class="form-label">O.R. Number</label> <input type="text" id="3aorNumberedit" name="3aorNumberedit" class="form-control" required> </div> </div> <div class="col-lg-4"> <div class="mb-1 position-relative" id="3adatePaidInputpickeredit"> <label class="form-label">Date Paid</label> <input type="text" data-date-autoclose="true" class="form-control" id="3adatePaidedit" name="3adatePaidedit" data-provide="datepicker" data-date-format="MM dd, yyyy" data-date-container="#3adatePaidInputpickeredit" required> </div> </div> </div> <div class="row"> <div class="col-lg-6"> <div class="mb-1"> <label for="3averify" class="form-label">Verified By</label> <input type="text" id="3averifyedit" name="3averifyedit" oninput="this.value = this.value.toUpperCase()" class="form-control" required> </div> </div> <div class="col-lg-6"> <div class="mb-1"> <label for="3amcr" class="form-label">Municipal Civil Registrar</label> <input type="text" id="3amcredit" name="3amcredit" oninput="this.value = this.value.toUpperCase()" value="ISMAEL D. MALICDEM, JR." class="form-control" required> </div> </div> </div> <div class="row"> <div class="col-lg-6"> <div class="mb-1"> <label for="3adesignation" class="form-label">Designation</label> <div class="dropdown"> <select id="3adesignationedit" name="3adesignationedit" class="form-select" required> <option value="" selected disabled></option> <option value="Administrative Aide I">Administrative Aide I</option> <option value="Administrative Aide II">Administrative Aide II</option> <option value="Administrative Aide III">Administrative Aide III</option> <option value="Administrative Assistant I">Administrative Assistant I</option> <option value="Others">Others</option> </select> <div class="row justify-content-center"> <div class="col-md-10"> <input type="text" class="form-control" id="3acustomInputedit" name="3acustomInputedit" placeholder="Position" style="display: none; margin-top: 5px" /> </div> </div> </div> </div> </div> <div class="col-lg-6"> <div class="mt-3"> <p id="filefolder3a" style="font-family: monospace; text-align: center; font-size: 15px"></p> </div> </div> </div> <div class="row justify-content-end" style="margin: 30px;"> <button class="buttonx" type="button" data-bs-dismiss="modal"> <i class="mdi mdi-cancel"></i> </button> <button class="button" type="submit"> Update → </button> <style> .buttonx { --font-color: #323232; --bg-color: #fff; --main-color: #323232; width: 50px; height: 40px; border-radius: 5px; border: 2px solid var(--main-color); background-color: var(--bg-color); box-shadow: 4px 4px var(--main-color); font-size: 17px; margin-right: 10px; font-weight: 600; color: var(--font-color); cursor: pointer; } .buttonx:focus { --bg-color: #fa5c7c; background-color: var(--bg-color); color: white; } .buttonx:hover { --bg-color: #fa5c7c; background-color: var(--bg-color); color: white; } .buttonx:active { box-shadow: 0px 0px var(--main-color); transform: translate(3px, 3px); } </style> <style> .button { --font-color: #323232; --bg-color: #fff; --main-color: #323232; width: 120px; height: 40px; border-radius: 5px; border: 2px solid var(--main-color); background-color: var(--bg-color); box-shadow: 4px 4px var(--main-color); font-size: 17px; font-weight: 600; color: var(--font-color); cursor: pointer; } .button:focus { --bg-color: #0acf97; background-color: var(--bg-color); color: white; } .button:active { box-shadow: 0px 0px var(--main-color); transform: translate(3px, 3px); } </style> </div> </form>