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online_application2.php
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online_application2.php
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<?php
session_start();
if(!isset($_SESSION['logged'])){
header("location: login.php");
}
require_once("connection/connection.php");
include 'support/header.php';
?>
<div class="container p-1">
<div class="border p-2">
<h1>Requirement Application</h1>
<form action="php/online_application_add.php" method="POST" onsubmit="return validateForm2()">
<ol>
<li>
<div class="form-group">
<label for="fullName">Full Name</label>
<label for="fullName">(සම්පූර්ණ නම)</label>
<input type="text" name="fullName" id="fullName" class="form-control">
</div>
</li>
<li>
<div class="form-group">
<label for="address">Address</label>
<label for="address">(ලිපිනය)</label>
<input type="text" name="address" id="address" class="form-control">
</div>
</li>
<div class="row no-gutters">
<li class="col-md-6">
<div class="form-group">
<label for="division">Grama Niladari Area</label>
<label for="division">(ග්රාම නිලධාරී වසම)</label>
<select name="division" id="division" class="form-control">
<option value="">Select Grama Niladhari Division</option>
<option value="164 Pamunugama">164 Pamunugama</option>
<option value="164/A Maha Pamunugama">164/A Maha Pamunugama</option>
<option value="165/A Bopitiya">165/A Bopitiya</option>
<option value="165 Bopitiya">165 Bopitiya</option>
<option value="166 Nugape">166 Nugape</option>
<option value="167 Uswetakriyyawa">167 Uswetakriyyawa</option>
<option value="168 Palliyawatta">168 Palliyawatta</option>
<option value="169 Hekiththa">169 Hekiththa</option>
<option value="169/A kurunduheena">169/A kurunduheena</option>
<option value="176 Wattala">176 Wattala</option>
</select>
</div>
</li>
<li class="col-md-4 ml-md-5">
<div class="form-group">
<label for="contact">Telephone number</label>
<label for="contact">(දුරකතන අංකය)</label>
<input type="text" name="contact" id="Contact" class="form-control">
</div>
</li>
</div>
<li>
<div class="form-group">
<label for="email">Email</label>
<label for="email">(විදයුත් ලිපිනය)</label>
<input type="text" name="email" id="email" class="form-control">
</div>
</li>
<li>
<div class="form-group">
<label for="requirement">Requirement<label>
<label for="requirement">(අවශ්යතාවය)</label>
<input type="text" name="requirement" id="requirement" class="form-control">
</div>
</li>
<div class="row no-gutters">
<li class="col-md-6">
<div class="form-group">
<label for="nic">ID No</label>
<label for="nic">(ජාතික හැදුහැදුනුම්පත් අංකය)</label>
<input type="text" name="nic" id="nic" class="form-control">
</div>
</li>
<li class="col-md-4 ml-md-5">
<div class="form-group">
<label for="gender">Gender</label>
<label for="gender">(ස්ත්රී/ පුරුෂ භාවය)</label>
<div class="form-check ml-5">
<input class="form-check-input" type="radio" name="gender" id="gender" value="Male">
<label class="form-check-label" for="exampleRadios1">
Male
</label>
</div>
<div class="form-check ml-5">
<input class="form-check-input" type="radio" name="gender" id="gender" value="Female">
<label class="form-check-label" for="exampleRadios2">
Female
</label>
</div>
</div>
</li>
</div>
</ol>
<div class="text-center mb-5" >
<p class="text-dark">I hereby confirm that I have inspected the above requirement of citizen who lives in Wattala division.</p>
</div>
<div class="row justify-content-center">
<div class="col-5 ml-md-5">
<p>-------------------<br>
Divisional secretary<br>
ප්රාදේශීය ලේකම්</p>
</div>
<div class="col-5 ml-md-5">
<p>-------------------<br>
Grama Niladhari <br>
ග්රාම නිලධාරී</p>
</div>
</div>
<!-- Payment Section -->
<hr>
<h1>Payment Section</h1>
<div class="row no-gutters">
<div class="form-group col-md-4 mr-md-5 ">
<label for="card_num">Credit card details</label>
<div class="input-group">
<input class="form-control" type="number" id="card_num" name="card_num" placeholder="1234 1234 1234 1234" required>
</div>
<span><i class="fab fa-cc-visa display-4"></i> <i class="fab fa-cc-mastercard display-4"></i> <i class="fab fa-cc-amex display-4"></i></span>
</div>
<div class="form-group col-md-6">
<label for="name">Card holder name</label>
<input type="text" name="name" id="name" placeholder="Card holder name" class="form-control" required>
</div>
</div>
<div class="row no-gutters">
<div class="form-group col-md-3 mr-md-5">
<label for="card_date">Credit card expire date</label>
<div class="input-group">
<input class="form-control" type="text" id="card_date" name="card_date" placeholder="MM/YY" required>
</div>
</div>
<div class="form-group col-md-3">
<label for="name">Amount</label>
Rs.
<input type="hidden" name="amount" id="amount" value="120.00" class="form-control" >
<input type="text" name="amount" id="amount" value="120.00" class="form-control" disabled >
</div>
</div>
<div class="form-group">
<input type="submit" value="Save" name="form2_save" class="btn">
</div>
</form>
</div>
</div>
<?php
include 'support/footer.php';
?>
<script src="js/online_application_add.js"></script>