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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>