Untitled
unknown
html
a year ago
21 kB
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<form action="" method="post" id="form3A">
<input type="hidden" name="type" id="typeInput" value="Form 3A">
<div class="row mt-3">
<div class="col-lg-4">
<div class="mb-1 position-relative" id="3adateInputpicker">
<label class="form-label">Date</label>
<input type="text" data-date-autoclose="true" class="form-control" id="3adate"
name="3adate" data-provide="datepicker" data-date-format="MM dd, yyyy"
data-date-container="#3adateInputpicker" required>
</div>
</div>
<div class="col-lg-4">
<div class="mb-1">
<label for="simpleinput" class="form-label">Page Number</label>
<input type="number" name="3apagenum" id="3apagenum" class="form-control">
</div>
</div>
<div class="col-lg-4">
<div class="mb-1">
<label for="simpleinput" class="form-label">Book Number</label>
<input type="number" name="3abooknum" id="3abooknum" 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 Name</label>
<input type="text" name="3agroomname" id="3agroomname" class="form-control">
</div>
</div>
<div class="col-lg-6">
<div class="mb-1">
<label for="simpleinput" class="form-label">Bride Name</label>
<input type="text" name="3abridename" id="3abridename" 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 Age</label>
<input type="text" name="3agroomage" id="3agroomage" class="form-control">
</div>
</div>
<div class="col-lg-6">
<div class="mb-1">
<label for="simpleinput" class="form-label">Bride Age</label>
<input type="text" name="3abrideage" id="3abrideage" 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 Citizenship</label>
<input type="text" name="3agroomcitizen" id="3agroomcitizen" 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="3abridecitizen" id="3abridecitizen" 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="3agroomcivil" id="3agroomcivil" 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="3abridecivil" id="3abridecivil" 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="3agroommother" id="3agroommother" 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="3abridemother" id="3abridemother" 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="3agroomfather" id="3agroomfather" 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="3abridefather" id="3abridefather" 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="3aregistrynum" id="3aregistrynum" class="form-control">
</div>
</div>
<div class="col-lg-6">
<div class="mb-1 position-relative" id="3adateInputpickerreg">
<label class="form-label">Date of Registration</label>
<input type="text" data-date-autoclose="true" class="form-control" id="3adatereg"
name="3adatereg" data-provide="datepicker" data-date-format="MM dd, yyyy"
data-date-container="#3adateInputpickerreg" required>
</div>
</div>
</div>
<div class="row">
<div class="col-lg-6">
<div class="mb-1 position-relative" id="3adateInputpickermar">
<label class="form-label">Date of Marriage</label>
<input type="text" data-date-autoclose="true" class="form-control" id="3adatemarriage"
name="3adatemarriage" data-provide="datepicker" data-date-format="MM dd, yyyy"
data-date-container="#3adateInputpickermar" 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="3aplacemarriage" id="3aplacemarriage" 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="3aissued" name="3aissued" 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="3aremarks" name="3aremarks" 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="amountPaidInput3a" name="amountPaidInput3a" 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="3aorNumber" name="3aorNumber" class="form-control" required>
</div>
</div>
<div class="col-lg-4">
<div class="mb-1 position-relative" id="3adatePaidInputpicker">
<label class="form-label">Date Paid</label>
<input type="text" data-date-autoclose="true" class="form-control" id="3adatePaid"
name="3adatePaid" data-provide="datepicker" data-date-format="MM dd, yyyy"
data-date-container="#3adatePaidInputpicker" 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="3averify" name="3averify"
value="<?php echo $userData['verified']; ?>"
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="3amcr" name="3amcr"
oninput="this.value = this.value.toUpperCase()" value="<?php echo $mcrValueString; ?>"
class="form-control" required>
</div>
</div>
</div>
<div class="row">
<div class="col-lg-6">
<div class="mb-1">
<label for="3adesignation" class="form-label">Designation</label>
<div class="dropdown">
<select id="3adesignation" name="3adesignation" class="form-select" required>
<option value="" selected disabled></option>
<option value="Administrative Aide I" <?php
if($userData['designation']=="Administrative Aide I" ) { echo "selected" ; }
?>
>Administrative Aide I</option>
<option value="Administrative Aide II" <?php
if($userData['designation']=="Administrative Aide II" ) { echo "selected" ;
} ?>
>Administrative Aide II</option>
<option value="Administrative Aide III" <?php
if($userData['designation']=="Administrative Aide III" ) { echo "selected" ;
} ?>
>Administrative Aide III</option>
<option value="Administrative Assistant I" <?php
if($userData['designation']=="Administrative Assistant I" ) {
echo "selected" ; } ?>>Administrative Assistant I</option>
<option value="Others" <?php if($userData['designation']=="Others" ) {
echo "selected" ; } ?>>Others</option>
</select>
<div class="row justify-content-center">
<div class="col-md-10">
<input type="text" value="<?php echo $userData['others']; ?>"
class="form-control" id="3acustomInput" name="3acustomInput"
placeholder="Position" style="display: none; margin-top: 5px" />
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row justify-content-end" style="margin: 30px;">
<button class="buttonx" type="button" data-bs-dismiss="modal">
<i class="mdi mdi-cancel"></i>
</button>
<button class="button" type="submit">
Save →
</button>
<style>
.buttonx {
--font-color: #323232;
--bg-color: #fff;
--main-color: #323232;
width: 50px;
height: 40px;
border-radius: 5px;
border: 2px solid var(--main-color);
background-color: var(--bg-color);
box-shadow: 4px 4px var(--main-color);
font-size: 17px;
margin-right: 10px;
font-weight: 600;
color: var(--font-color);
cursor: pointer;
}
.buttonx:focus {
--bg-color: #fa5c7c;
background-color: var(--bg-color);
color: white;
}
.buttonx:hover {
--bg-color: #fa5c7c;
background-color: var(--bg-color);
color: white;
}
.buttonx:active {
box-shadow: 0px 0px var(--main-color);
transform: translate(3px, 3px);
}
</style>
<style>
.button {
--font-color: #323232;
--bg-color: #fff;
--main-color: #323232;
width: 120px;
height: 40px;
border-radius: 5px;
border: 2px solid var(--main-color);
background-color: var(--bg-color);
box-shadow: 4px 4px var(--main-color);
font-size: 17px;
font-weight: 600;
color: var(--font-color);
cursor: pointer;
}
.button:focus {
--bg-color: #0acf97;
background-color: var(--bg-color);
color: white;
}
.button:active {
box-shadow: 0px 0px var(--main-color);
transform: translate(3px, 3px);
}
</style>
<div class="mt-1">
<div class="form-check">
<input type="radio" id="saveoption3a" name="3aOptionRadio" class="form-check-input"
value="1" <?php if ($userData['saveas']=='1' ) { echo 'checked' ; } ?>>
<label style=" -webkit-user-select: none; /* Safari */
-moz-user-select: none; /* Firefox */
-ms-user-select: none; /* IE10+/Edge */
user-select: none; /* Standard */
-webkit-touch-callout: none; /* Disable long press on mobile */
-khtml-user-select: none; /* Konqueror HTML */
-webkit-tap-highlight-color: transparent; /* Remove tap highlight color */"
class="form-check-label" for="saveoption3a">Save to Database Only</label>
</div>
<div class="form-check">
<input type="radio" id="saveoption23a" name="3aOptionRadio" class="form-check-input"
value="2" <?php if ($userData['saveas']=='2' ) { echo 'checked' ; } ?>>
<label style=" -webkit-user-select: none; /* Safari */
-moz-user-select: none; /* Firefox */
-ms-user-select: none; /* IE10+/Edge */
user-select: none; /* Standard */
-webkit-touch-callout: none; /* Disable long press on mobile */
-khtml-user-select: none; /* Konqueror HTML */
-webkit-tap-highlight-color: transparent; /* Remove tap highlight color */"
class="form-check-label" for="saveoption23a">Save and Generate Document</label>
<br>
<br>
<br>
<p style="font-family: monospace; text-align: center; font-size: 15px">
<?php
if ($userData['folderpath'] == 'default' || $userData['folderpath'] == 'DEFAULT') {
echo 'Filepath is set to (default) <br><span id="filepath" onclick="copyText()">C:\\Form Generated\\</span>';
} else {
echo 'Filepath is set to <br><span id="filepath" onclick="copyText()">' . $userData['folderpath'] . '/</span>';
}
?>
</p>
</div>
</div>
</div>
</form>