@extends ('helpers.base')

@section ('jsPageBottom')
<script type="text/javascript">var logout = {{ (Session::has('logout'))?1:0}}</script>
<script type="text/javascript">var requireLogin = {{ (Session::has('requireLogin'))?1:0}}</script>
{{ HTML::script('admin/template/js/jquery.bxslider.js')}}
{{ HTML::script('admin/template/js/home.js')}}
@stop
@section ('jsPage')
<script type="text/javascript">
    var rootBase = "{{ asset('') }}";
</script>
<script src="{{ asset('admin/template/js/home.register.js') }}"></script>
@stop

@section ('pageContent')
<div id="center-body">
    <div id="title-background">
        <div id="title-body-registration">
            <p id="text-left-body-registration"> REGISTRATION FORM </p>

            <p id="text-right-body"></p>
        </div>
    </div>
    <div id="slider-central-registration">
        <div id="form-container-registration">
            @if($errors->count()>0)
            <div class="alert alert-danger" id="alert">
                <ul>
                    @foreach($errors->all() as $error)
                    <li>
                        {{ $error }}
                    </li>
                    @endforeach
                </ul>
            </div>
            @endif
            @if(Session::has('failed'))
            <div class="alert alert-danger align-right" id="alert">
                <p>{{ Session::get('failed') }}</p>
            </div>
            @endif
            @if(Session::has('msg'))
            <div class="alert alert-success align-right" id="alert">
                <p>{{ Session::get('msg') }}</p>
            </div>
            @endif
            <div id="basic-information">
                <!--<form name="form" id="update-form-hoa" action="">-->
                {{Form::open(['route'=>'registration.signup'])}}
                <div id="form-basic-information-registration">
                    <!-- INICIO primer campo de inputs -->
                    <div id="column" class="row">
                        <div class="col-xs-8">
                            <p> Company Name: </p>
                            {{ Form::text('company_name', null, ['id'=>'', 'class' => 'form-control center']) }}
                        </div>
                    </div>
                    <!-- FIN primer campo de inputs -->
                    <!-- INICIO segundo campo de inputs -->
                    <div id="column" class="row">
                        <div class="col-xs-8">
                            <p> Contact Name: </p>
                            {{ Form::text('contact_name', null, ['id'=>'', 'class' => 'form-control center']) }}
                        </div>
                    </div>
                    <!-- FIN segundo campo de inputs -->
                    <!-- INICIO tercer campo de inputs -->
                    <div id="column" class="row">
                        <div class="col-xs-8">
                            <p> Company Address: </p>
                            {{ Form::text('address', null, ['id'=>'', 'class' => 'form-control center']) }}
                        </div>
                    </div>
                    <!-- FIN tercer campo de inputs -->
                    <!-- INICIO cuarto campo de inputs -->
                    <div id="column" class="row">
                        <div class="col-xs-4">
                            <p> City: </p>
                            {{ Form::select('city_id', $select + $cities, null, ['id'=>'city_id', 'class' =>'form-control center']) }}
                        </div>
                        <div class="state">
                            <div class="col-xs-4">
                                <p> State: </p>
                                {{ Form::select('state_id', ($select + $states), null, ['id'=>'state_id', 'class' =>'form-control center']) }}
                            </div>
                        </div>
                        <div class="col-xs-3">
                            <p> Zip Code: </p>
                            {{ Form::text('zipcode', null, ['id'=>'', 'class' => 'form-control center']) }}
                        </div>
                    </div>
                    <!-- FIN cuarto campo de inputs -->
                    <!-- INICIO 5to campo de inputs -->
                    <div id="column" class="row">
                        <div class="col-xs-4">
                            <p> Email: </p>
                        </div>
                        <div class="col-md-3">
                            <p id="text-primary"> Primary Contact Phone: </p>
                        </div>
                        <div class="col-md-1">
                            <p> Ext: </p>
                        </div>
                        <div class="col-md-4">
                            <p> Fax: </p>
                        </div>
                        <div class="col-xs-4">
                            {{ Form::text('email', null, ['id'=>'', 'class' => 'form-control center']) }}
                        </div>
                        <div class="col-md-1">
                            {{ Form::text('phone[1]', Input::old('phone.1'), ['id'=>'', 'class'=>'form-control-especial center', 'maxlength'=>'3']) }}
                        </div>
                        <div class="col-md-1">
                            {{ Form::text('phone[2]', Input::old('phone.2'), ['id'=>'', 'class'=>'form-control-especial center', 'maxlength'=>'3']) }}
                        </div>
                        <div class="col-md-1">
                            {{ Form::text('phone[3]', Input::old('phone.3'), ['id'=>'', 'class'=>'form-control-especial center', 'maxlength'=>'4']) }}
                        </div>
                        <div class="ext">
                            <div class="col-md-1">
                                {{ Form::text('phone[ext]', Input::old('phone.ext'), ['id'=>'', 'class'=>'form-control-especial center'])}}
                            </div>
                        </div>
                        <div class="col-md-1" id="fax">
                            {{ Form::text('fax[1]', Input::old('fax.1'), ['id'=>'', 'class'=>'form-control-especial center', 'maxlength'=>'3']) }}
                        </div>
                        <div class="col-md-1" id="fax">
                            {{ Form::text('fax[2]', Input::old('fax.2'), ['id'=>'', 'class'=>'form-control-especial center', 'maxlength'=>'3']) }}
                        </div>
                        <div class="col-md-1" id="fax">
                            {{ Form::text('fax[3]', Input::old('fax.3'), ['id'=>'', 'class'=>'form-control-especial center', 'maxlength'=>'4']) }}
                        </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-registration">
                    <!-- Upload document -->
                    <div id="column" class="row">
                        <div class="col-xs-12">
                            <p> Seminar/Conference; if so which one?: </p>
                        </div>
                        <div class="col-xs-12">
                            <textarea name="comment[]" id="update-specific-hoa" class="form-control" rows="3"></textarea>
                            <input name="question[]" value="Seminar/Conference; if so which one?" type="hidden">
                        </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="comment[]" id="update-specific-hoa" class="form-control" rows="3"></textarea>
                            <input name="question[]" value="Referral; if so from whom so we can thank them?" type="hidden">
                        </div>
                        <div class="col-xs-12">
                            <p> Internet Search,which search engine?: </p>
                        </div>
                        <div class="col-xs-12">
                            <textarea name="comment[]" id="update-specific-hoa" class="form-control" rows="3"></textarea>
                            <input name="question[]" value="Internet Search,which search engine?" type="hidden">
                        </div>
                        <div class="col-xs-12">
                            <p> Other: </p>
                        </div>
                        <div class="col-xs-12">
                            <textarea name="comment[]" id="update-specific-hoa" class="form-control" rows="3"></textarea>
                            <input name="question[]" value="Other" type="hidden">
                        </div>
                    </div>
                    <!--  FIN Upload document -->
                </div>
                @include('site.buttonsSubmit')
                {{Form::close()}}
            </div>
        </div>
    </div>
    @include ('helpers.footer')
</div>
@stop