@extends('cpanel.layouts.main')

@section('pagejs')
<script type="text/javascript" src="{{ asset('admin/assets/js/request.update.js') }}"></script>
@stop

@section('triggerjs')
requestUpdate.init();
@stop

@section('content')
<div class="page-header">
    <div class="page-title">
        <h3>Request List</h3>
        <span>Good morning, John!</span>
    </div>
</div>

<div class="row">
    <div class="col-md-12">
        <div class="widget box">
            <div class="widget-content">
                {{ Form::open(['route'=>['admin.request.update', $request->id], 'class'=>'form-horizontal row-border']) }}
                <div class="form-group">
                    <label class="col-md-2 control-label">Companies Listed </label>
                    <div class="col-md-3">
                        {{ Form::select('company_listed', ($select + [0=>'register it'] + $companies), Input::old('company_listed'), ['class'=>'form-control']) }}
                        {{ $errors->first('company_listed') }}
                    </div>
                </div>
                <div class="form-group">
                    <label class="col-md-2 control-label">Company Name </label>
                    <div class="col-md-4">
                        {{ Form::text('company_name', Input::old('company_name',$request->company_name), ['class'=>'form-control company_name']) }}
                        {{ $errors->first('company_name') }}
                    </div>
                </div>
                <div class="form-group">
                    <label class="col-md-2 control-label">Contact Name </label>
                    <div class="col-md-4">
                        {{ Form::text('contact_name', Input::old('contact_name',$request->contact_name), ['class'=>'form-control']) }}
                        {{ $errors->first('contact_name') }}
                    </div>
                </div>
                <div class="form-group">
                    <label class="col-md-2 control-label">Company Address: </label>
                    <div class="col-md-6">
                        {{ Form::text('address', Input::old('address',$request->address), ['class'=>'form-control']) }}
                    </div>
                </div>
                <div class="form-group">
                    <label class="col-md-2 control-label">State </label>
                    <div class="col-md-3">
                        {{ Form::select('state_id', ($select + $states), Input::old('state_id',$request->state_id), ['class'=>'form-control']) }}
                    </div>
                    <label class="col-md-1 control-label">City </label>
                    <div class="col-md-3">
                        {{ Form::select('city_id', ($select), Input::old('city_id', $request->city_id), ['class'=>'form-control']) }}
                    </div>
                    <label class="col-md-1 control-label">zipcode </label>
                    <div class="col-md-2">
                        {{ Form::text('zipcode', Input::old('zipcode',$request->zipcode), ['class'=>'form-control']) }}
                    </div>
                </div>

                <div class="form-group">
                    <label class="col-md-2 control-label">Email </label>
                    <div class="col-md-3">
                        {{ Form::text('email', Input::old('email',$request->email), ['class'=>'form-control']) }}
                        {{ $errors->first('email') }}
                    </div>
                    <label class="col-md-2 control-label">Primary Contact Phone </label>
                    <div class="col-md-2">
                        {{ Form::text('phone', Input::old('phone',$request->phone), ['class'=>'form-control']) }}
                        {{ $errors->first('phone') }}
                    </div>

                    <label class="col-md-1 control-label">Fax </label>
                    <div class="col-md-2">
                        {{ Form::text('fax', Input::old('fax',$request->fax), ['class'=>'form-control']) }}
                        {{ $errors->first('fax') }}
                    </div>
                </div>

                <div class="form-group">
                    <label class="col-md-2 control-label">Username </label>
                    <div class="col-md-4">
                        {{ Form::text('username', Input::old('username'), ['class'=>'form-control']) }}
                        {{ $errors->first('username') }}
                    </div>
                    <label class="col-md-2 control-label">Password </label>
                    <div class="col-md-4">
                        {{ Form::password('password', ['class'=>'form-control']) }}
                        {{ $errors->first('password') }}
                    </div>
                </div>

                <div class="btn-toolbar align-right">
                    <button type="submit" class="btn btn-primary save">Save</button>
                    <button onclick="window.location='{{ URL::route('admin.request.index') }}'" type="button" class="btn" data-toggle="button">Close</button>
                </div>

                {{ Form::close() }}
            </div>
        </div>
    </div>
</div>

@stop