@extends('layouts.applicant1')

@section('content')
<div class="row">
	<div class="page-header">
	<h3 style="color:maroon">Enter Your Details</h3>
		
	</div> 
	
</div>
@if (count($errors) > 0)
<div class="alert-warning">
	<pre>If you get an error, Id number has already been taken, it means you already have account with us. Kindly click on Login and click forgot Email to recover your Account details. <a href="{{url('/logout')}}">Click here</a> to access that option</pre>
	
</div>
    <div class="alert alert-danger">
        <ul>
            @foreach ($errors->all() as $error)
                <li>{{ $error }}</li>
            @endforeach
        </ul>
    </div>
@endif
<form action="applicantregister" method="POST">
	<div class="row">
		<input type="hidden" name="_token" value="{{csrf_token() }}">
		
	</div>
	<div class="row">
		<div class="col-sm-3">
			<div class="form-group">
				<label>
					First Name
				</label>
				<input type="text" name="firstname" class="form-control" placeholder="First Name" value="{{old('firstname')}}" required>
				
			</div>
			
		</div>
		<div class="col-sm-3">
			<div class="form-group">
				<label>
					Middle Name
				</label>
				<input type="text" name="middlename" class="form-control" placeholder="Middle Name" value="{{old('middlename')}}">
				
			</div>
			
		</div>
		<div class="col-sm-3">
			<div class="form-group">
				<label>
					Last Name
				</label>
				<input type="text" name="lastname" class="form-control" placeholder="Last Name" value="{{old('lastname')}}" required>
				
			</div>
			
		</div>
		<div class="col-sm-3">
			<div class="form-group">
				<label>
					Postal Address
				</label>
				<input type="text" name="postaladdress" class="form-control" placeholder="Postal Address" value="{{old('postaladdress')}}" required>
				
			</div>
			
		</div>
		
		
	</div>
	<div class="row">
		<div class="col-sm-3">
			<div class="form-group">
				<label>
					Postal Code
				</label>
				<input type="text" name="postalcode" class="form-control" placeholder="Postal Code" value="{{old('postalcode')}}" required>
				
			</div>
			
		</div>
		<div class="col-sm-3">
			<div class="form-group">
				<label>
					Town
				</label>
				<input type="text" name="town" class="form-control" placeholder="Town" value="{{old('town')}}" required>
				
			</div>
			
		</div>
		<div class="col-sm-3">
			<div class="form-group" required>
				<label>
					ID/Birth Cert No.
				</label>
				<input type="text" name="nationalid" class="form-control" maxlength="12" placeholder="ID/Birth Cert No." value="{{old('nationalid')}}" required>
				
			</div>
			
		</div>
		<div class="col-sm-3">
				<div class="form-group">
					<label>
					Gender  <span style="color:red;"> *</span> 
					</label>
					<div class="radio">
						<label>
							<input type="radio" name="gender" id="optionsRadios1" value="M" required="">Male
						</label>
					</div>
					<div class="radio">
						<label>
							<input type="radio" name="gender" id="optionsRadios2" value="F">Female
						</label>
					</div>
							
				</div>
									
			</div>
		
		
		
		
	</div>
	
	<div class="row">
			<div class="col-sm-3">
					<div class="form-group" required>
						<label>
							Date of Birth
						</label>
						<input type="text" name="dateofbirth" class="form-control datetimepicker" value="{{old('dateofbirth')}}" placeholder="Date of Birth" required>
						
					</div>
					
				</div>
			
		<div class="col-sm-3">
			<div class="form-group">
				<label>
					Nationality
				</label>
				<select class="form-control" name="nationality">
					<option value="">Select...</option>
					@foreach($country as $c)
					<option value="{{$c->id}}">{{$c->full_name}}</option>

					@endforeach
					
				</select>
				
			</div>
			
		</div>
		<div class="col-sm-3">
			<div class="form-group">
				<label>
					County
				</label>
				<select class="form-control select2" name="county" id="county">
					<option value="">Select...</option>
					@foreach($county as $c)
					<option value="{{$c->id}}">{{$c->name}}</option>

					@endforeach
					
				</select>
				
			</div>
			
		</div>
		<div class="col-sm-3">
			<div class="form-group">
				<label>
					Sub County
				</label>
				<select class="form-control select2" name="subcounty" id='subcounty'>
					
					<option value="">--please selct county--</option>
					
				</select>
				
			</div>
			
		</div>
		
		
		
	</div>
	<div class="row">
			<div class="col-sm-3">
					<div class="form-group">
						<label>
							Constituency
						</label>
						<select class="form-control select2" name="constituency" id="const">
							<option value="">Please select subcounty</option>
							
							
						</select>
						
					</div>
					
				</div>	
		
		<div class="col-sm-3">
			<div class="form-group" required>
				<label>
					Year of Examination
				</label>
				<select class="form-control" name="yearofexamination">
					<option value="">Select...</option>
										@for($i=$year; $i>=1980; $i--)
					
					<option value="{{ $i }}">{{ $i }}</option>
					@endfor
					
				</select>
				
			</div>
			
		</div>
		<div class="col-sm-3">
			<div class="form-group">
				<label>
					Index Number
				</label>
				<input type="text" name="indexnumber" class="form-control" placeholder="Index Number" value="{{old('indexnumber')}}" required maxlength="12">
				
			</div>
			
		</div>
		<div class="col-sm-3">
			<div class="form-group">
				<label>
				 Applicant's Phone(e.g.712345678)
				</label>
				<input type="text" name="phone1" maxlength="10" class="form-control" placeholder="Phone Number 1" value="{{old('phone1')}}" required>
				
			</div>
			
		</div>
		
		
	</div>
	<div class="row">
			<div class="col-sm-3">
					<div class="form-group">
						<label>
							Alternative Phone(e.g.712345678)
						</label>
						<input type="text" name="phone2" maxlength="10" class="form-control" placeholder="Phone Number 2" value="{{old('phone2')}}" required>
						
					</div>
					
				</div>
		<div class="col-sm-3">
			<div class="form-group">
				<label>
					Name of Next of Kin
				</label>
				<input type="text" name="nameofnextofkin" class="form-control" placeholder="Name of Next of Kin" value="{{old('nameofnextofkin')}}" required>
				
			</div>
			
		</div>
		<div class="col-sm-3">
			<div class="form-group">
				<label>
					Relationship
				</label>
				<select class="form-control" name="relationship">
					<option value="">Select...</option>
					<option value="Brother">Brother</option>
					<option value="Sister">Sister</option>
					<option value="Parent">Parent</option>
					<option value="Guardian">Guardian</option>
					
				</select>
				
			</div>
			
		</div>
		
		
	</div>
	<div class="row" style="background-color:maroon; color:white">
		<h5>Disability Assessment</h5>
		<h6>Please note that disability information is required for planning purposes and not creteria for selection</h6>
		
	</div>
	<div class="row">
		<div class="col-sm-5">
	        <div class="form-group">
                <label>
                Do you consider yourself Disabled person?<span style="color:red;"> *</span> 
                </label>
                <div class="radio">
                    <label>
                        <input type="radio" name="disability" id="optionsRadios1" value="Yes" required="">Yes
                    </label>
                </div>
                <div class="radio">
                    <label>
                        <input type="radio" name="disability" id="optionsRadios2" value="No">No
                    </label>
                </div>
	                    
	        </div>
                                
        </div>
       
       
		
		
		
		
	</div>
	<div class="row">
	 <span class="divdisa">
		 <div class="col-sm-2">
	        <div class="form-group">
                <label>
                Type/Class<span style="color:red;"> *</span> 
                </label>
                <div class="radio">
                    <label>
                        <input type="radio" name="disabilitytype" id="optionsRadios1" value="Physical">Physical
                    </label>
                </div>
                <div class="radio">
                    <label>
                        <input type="radio" name="disabilitytype" id="optionsRadios2" value="Mental">Mental
                    </label>
                </div>
	                    
	        </div>
                                
        </div>
		<div class="col-sm-6">
			<div class="form-group">
				<label>
					Give Details of Nature of Disability<span style="color:red;"> *</span>
				</label>
				<textarea class="form-control" rows="5" name="disabilitydetails"></textarea>
				
			</div>
			
		</div>
		</span>
		
	</div>
	
	<div class="row">
		<div class="col-sm-3">
			<input type="submit" name="submit" class="btn btn-primary btn-outline">
			
		</div>
		
	</div>
	
</form>

<script src="{{ asset('assets/sba/bower_components/jquery/dist/jquery.min.js') }}"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/bootstrap-datepicker/1.8.0/js/bootstrap-datepicker.js"></script>
<script type="text/javascript">

	$(document).ready(function(){
		
		$(".commit").hide();
		$("#req").change(function(){
			if($(this).val()==="Y"){
				$(".commit").show();
			}else{
				$(".commit").hide();	
			}
		});
	});
</script>

<script src="https://cdnjs.cloudflare.com/ajax/libs/bootstrap-datepicker/1.8.0/js/bootstrap-datepicker.js"></script>
<script type="text/javascript">
$('.datetimepicker').datepicker();
</script>
@stop