Untitled
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2 years ago
15 kB
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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="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>
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