<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN"
    "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
    <link href="http://firstimage.us/projectvj/registration/css/bootstrap.css" rel="stylesheet" media="screen">
    <link href="http://firstimage.us/projectvj/registration/css/registration-form.css" type="text/css" rel="stylesheet"
          media="all"/>
    <script src="http://firstimage.us/projectvj/registration/js/jquery.js"></script>
    <script src="http://firstimage.us/projectvj/registration/js/bootstrap.js"></script>
    <script type="text/javascript">
        var rootBase = "<?php echo asset(''); ?>";
    </script>
    <script src="<?php echo asset('website/js/home.register.js'); ?>"></script>
    <meta http-equiv="Content-Type" content="text/html; charset=utf-8"/>
    <title>Registration Form saury</title>
</head>
<body>
<div id="total-body">
<div id="header">
    <div id="login">
        <a href="#" id="login-button" title="Login">Login</a>
    </div>
    <div id="top-banner">
        <i id="banner"></i>
        <p>
            YOU CAN CHECK THE STATUS OF YOUR FILE AND DOWNLOAD IT, IT'S EASY FIND OUT HOW
        </p>
        <a href="#" id="boton-chat"></a>
    </div>
    <div id="nav-background">
        <div id="nav-top">
            <nav class="navbar navbar-default" role="navigation">
                <div class="container">
                    <ul class="nav navbar-nav">
                        <li id="home" class="<?php echo HTML::activeState('/'); ?>">
                            <a href="<?php echo route('home'); ?>">HOME</a>
                        </li>
                        <li class="<?php echo HTML::activeState('turnAroundTimes'); ?>">
                            <a href="<?php echo route('home.turnAroundTimes'); ?>">TURNAROUND TIMES</a>
                        </li>
                        <li class="<?php echo HTML::activeState('taxCollector'); ?>">
                            <a href="<?php echo route('home.taxCollector'); ?>">TAX COLLECTOR</a>
                        </li>
                        <li class="<?php echo HTML::activeState('municipalNumbers'); ?>">
                            <a href="<?php echo route('home.municipalNumbers'); ?>">MUNICIPAL NUMBERS</a>
                        </li>
                        <li class="dropdown">
                            <a href="#" class="dropdown-toggle" data-toggle="dropdown">ORDER FORMS <span
                                    class="caret"></span></a>
                            <ul class="dropdown-menu" role="menu">
                                <li class=""><a href="<?php echo route('order.lien.create'); ?>">LIEN ONLY</a></li>
                                <li class=""><a href="<?php echo route('order.hoa.create'); ?>">HOA ONLY</a></li>
                                <li class=""><a href="<?php echo route('order.both.create'); ?>">BOTH LIEN AND HOA</a>
                                </li>
                            </ul>
                        </li>
                        <li class="dropdown">
                            <a href="#" class="dropdown-toggle" data-toggle="dropdown">UPDATE ORDER<span
                                    class="caret"></span></a>
                            <ul class="dropdown-menu" role="menu">
                                <li class=""><a href="<?php echo route('order.lien.edit'); ?>">LIEN ONLY</a></li>
                                <li class=""><a href="<?php echo route('order.lien.edit'); ?>">HOA ONLY</a></li>
                                <li class=""><a href="<?php echo route('order.both.edit'); ?>">BOTH LIEN AND HOA</a></li>
                            </ul>
                        </li>
                        <li class="dropdown ">
                            <a href="#" class="dropdown-toggle" data-toggle="dropdown">CHECK STATUS <span
                                    class="caret"></span></a>
                            <ul class="dropdown-menu" role="menu">
                                <li class=""><a href="<?php echo route('order.lien.index'); ?>">CHECK STATUS LIEN</a></li>
                                <li class=""><a href="<?php echo route('order.hoa.index'); ?>">CHECK STATUS HOA</a></li>
                            </ul>
                        </li class="<?php echo HTML::activeState('home'); ?>">
                        <li class=""><a href="<?php echo route('home.contactUs'); ?>">CONTACT US</a></li>
                    </ul>
                </div>
            </nav>
        </div>
    </div>
</div>
<div id="center-body">
<div id="title-background">
    <div id="title-body">
        <p id="text-left-body">REGISTRATION FORM</p>
        <p id="text-right-body"></p>
    </div>
</div>
<div id="slider-central">
<div id="form-container">
<div id="title-section">
    <p>
        <?php if(Session::has('error') && !Session::get('error')): ?>
        <?php echo $msg; ?>

        <?php elseif(Session::has('error') && Session::get('error')): ?>
        <?php echo $msg; ?>

        <?php endif; ?>
    </p>
</div>
<div id="basic-information">
<!--<form name= "form" id="update-form-hoa" action="">-->
<?php echo Form::open(['route'=>'home.signup']); ?>

<div id="form-basic-information">
    <!-- INICIO primer campo de inputs -->
    <div id="column" class="row">

        <div class="col-xs-12">
            <p>
                Company Name:
            </p>
        </div>

        <div class="col-xs-12">
            <?php echo Form::text('company_name', null, ['id'=>'', 'class' => 'form-control']); ?>

            <?php echo $errors->first('company_name'); ?>

        </div>

    </div>
    <!-- FIN primer campo de inputs -->
    <!-- INICIO segundo campo de inputs -->
    <div id="column" class="row">

        <div class="col-xs-12">
            <p>
                Contact Name:
            </p>
        </div>

        <div class="col-xs-12">
            <?php echo Form::text('contact_name', null, ['id'=>'', 'class' => 'form-control']); ?>

            <?php echo $errors->first('contact_name'); ?>

        </div>

    </div>
    <!-- FIN segundo campo de inputs -->
    <!-- INICIO tercer campo de inputs -->
    <div id="column" class="row">

        <div class="col-xs-12">
            <p>
                Company Address:
            </p>
        </div>

        <div class="col-xs-12">
            <?php echo Form::text('address', null, ['id'=>'', 'class' => 'form-control']); ?>

            <?php echo $errors->first('address'); ?>

        </div>

    </div>
    <!-- FIN tercer campo de inputs -->
    <!-- INICIO cuarto campo de inputs -->
    <div id="column" class="row">

        <div class="col-xs-4">
            <p>
                State:
            </p>
        </div>
        <div class="col-xs-4">
            <p>
                City:
            </p>
        </div>
        <div class="col-xs-4">
            <p>
                Zip Code:
            </p>
        </div>

        <div class="col-xs-4">
            <?php echo Form::select('state_id', ($select + $states), null, ['id'=>'state_id', 'class' => 'form-control']); ?>

            <?php echo $errors->first('state_id'); ?>

        </div>
        <div class="col-xs-4">
            <?php echo Form::select('city_id', $select, null, ['id'=>'city_id', 'class' => 'form-control']); ?>

            <?php echo $errors->first('city_id'); ?>

        </div>
        <div class="col-xs-4">
            <?php echo Form::text('zipcode', null, ['id'=>'', 'class' => 'form-control']); ?>

            <?php echo $errors->first('zipcode'); ?>

        </div>

    </div>
    <!-- FIN cuarto campo de inputs -->
    <!-- INICIO 5to campo de inputs -->
    <div id="column" class="row">
        <div class="col-md-4">
            <p>Email:</p>
            <?php echo Form::text('email', null, ['id'=>'', 'class' => 'form-control']); ?>

            <?php echo $errors->first('email'); ?>

        </div>
        <div class="col-md-2">
            <p>Primary Contact Phone:</p>
            <?php echo Form::text('phone[1]', Input::old('phone.1'), ['id'=>'', 'class' => 'form-control']); ?>

            <?php echo $errors->first('phone'); ?>

        </div>
        <div class="col-md-2">
            <?php echo Form::text('phone[2]', Input::old('phone.2'), ['id'=>'', 'class' => 'form-control']); ?>

        </div>
        <div class="col-md-2">
            <?php echo Form::text('phone[3]', Input::old('phone.3'), ['id'=>'', 'class' => 'form-control']); ?>

        </div>
        <div class="col-md-2">
            <p>Ext:</p>
            <?php echo Form::text('phone[ext]', Input::old('phone.ext'), ['id'=>'', 'class' => 'form-control']); ?>

        </div>
        <div class="col-md-2">
            <p>Fax:</p>
            <?php echo Form::text('fax[1]', Input::old('fax.1'), ['id'=>'', 'class' => 'form-control']); ?>

            <?php echo $errors->first('fax'); ?>

        </div>
        <div class="col-md-2">
            <?php echo Form::text('fax[2]', Input::old('fax.2'), ['id'=>'', 'class' => 'form-control']); ?>

        </div>
        <div class="col-md-2">
            <?php echo Form::text('fax[3]', Input::old('fax.3'), ['id'=>'', 'class' => 'form-control']); ?>

        </div>
        <div class="col-md-1">
            <p>&nbsp;

            </p>
        </div>
    </div>
    <!-- FIN 5to campo de inputs -->
</div>
<div id="title-section">
    <p>How did you hear about us</p>
</div>
<div id="form-upload-document">
    <!-- Upload document -->
    <div id="column" class="row">
        <div class="col-xs-12">
            <p>Seminar/Conference; if so witch one?:</p>
        </div>
        <div class="col-xs-12">
            <textarea name="specific-instructions" id="update-specific-hoa" class="form-control" placeholder="Specific instructions" rows="3"></textarea>
        </div>
        <div class="col-xs-12">
            <p>Referral; if so from whom so we can thank them?:</p>
        </div>

        <div class="col-xs-12">
            <textarea name="specific-instructions" id="update-specific-hoa" class="form-control" placeholder="Specific instructions" rows="3"></textarea>
        </div>
        <div class="col-xs-12">
            <p>Internet Search,which search engine?:</p>
        </div>

        <div class="col-xs-12">
            <textarea name="specific-instructions" id="update-specific-hoa" class="form-control" placeholder="Specific instructions" rows="3"></textarea>
        </div>
        <div class="col-xs-12">
            <p>Other:</p>
        </div>
        <div class="col-xs-12">
            <textarea name="specific-instructions" id="update-specific-hoa" class="form-control" placeholder="Specific instructions" rows="3"></textarea>
        </div>
    </div>
    <!--  FIN Upload document -->
</div>
<div id="form-submit">
    <div id="special-column" class="row">
        <div class="col-md-4">
            &nbsp;
        </div>
        <div class="col-md-2">
            <div class="btn-group">
                <button id="button-cancel-form" name="button-cancel-form" type="button" class="btn btn-default">
                    Cancel
                </button>
            </div>
        </div>
        <div class="col-md-2">
            <div class="btn-group">
                <button id="button-submit-form" name="button-submit-form" type="submit" class="btn btn-default">
                    Submit
                </button>
            </div>
        </div>
        <div class="col-md-4">
            &nbsp;
        </div>
    </div>
    <?php echo Form::close(); ?>

    <!--</form>-->
</div>
</div>
</div>
</div>
<div id="footer">
    <div id="contact">
        <h5>CONTACT INFORMATION</h5>
        <span>Physical Address:</span>
        <span>One-Step Lien Search LLC | 13155 SW 42 ST Suite 202</span>
        <span>Miami, FL 33175 | order@onesteplien.com</span>
    </div>
</div>
<div id="copyright">
    Copyright © 2014 - All Rights Reserved
</div>
</div>
</div>
</div>
</body>
</html>