Untitled
html
a month ago
15 kB
0
Indexable
Never
<form method="post" id="form3Aedit" class="needs-validation" novalidate> <input type="hidden" name="id3a" id="id3a" > akosiralph <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="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="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 $userData['verified']; ?>" oninput="this.value = this.value.toUpperCase()" class="form-control" required> </div> </div> <div class="col-lg-6"> <div class="mb-1"> <label for="3amcr" class="form-label">Municipal Civil Registrar</label> <input type="text" id="3amcr" name="3amcr" oninput="this.value = this.value.toUpperCase()" value="ISMAEL D. MALICDEM, JR." class="form-control" required> </div> </div> </div> <div class="row"> <div class="col-lg-6"> <div class="mb-1"> <label for="3adesignation" class="form-label">Designation</label> <div class="dropdown"> <select id="3adesignation" name="3adesignation" class="form-select" required> <option value="" selected disabled></option> <option value="Administrative Aide I" <?php if($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>