Last active
June 29, 2016 12:56
-
-
Save accessomnath/483aece63bd04829e172628fdc5117eb to your computer and use it in GitHub Desktop.
This file contains hidden or bidirectional Unicode text that may be interpreted or compiled differently than what appears below. To review, open the file in an editor that reveals hidden Unicode characters.
Learn more about bidirectional Unicode characters
<?php | |
/** | |
* Created by PhpStorm. | |
* User: somnath | |
* Date: 21/6/16 | |
* Time: 7:38 PM | |
* | |
* Template Name: registration | |
*/ | |
get_header(); | |
if (isset($_POST['submit'])) { | |
// EDIT THE 2 LINES BELOW AS REQUIRED | |
$email_to = "[email protected]"; | |
$email_subject = "Online Application"; | |
function died($error) | |
{ | |
// your error code can go here | |
echo "We are very sorry, but there were error(s) found with the form you submitted. "; | |
echo "These errors appear below.<br /><br />"; | |
echo $error . "<br /><br />"; | |
echo "Please go back and fix these errors.<br /><br />"; | |
die(); | |
} | |
$title = $_POST['title']; | |
if (isset($title) && count($title) > 0) { | |
$title = implode(',', $title); | |
} else { | |
$title = ''; | |
} | |
$first_name = $_POST['fore_name']; // required | |
$last_name = $_POST['sur_name']; // required | |
$addressOne = $_POST['address_1']; // required | |
$postal_code = $_POST['postal_code']; // required | |
$daytime_telephone = $_POST['daytime_telephone']; // required | |
$mobile_no = $_POST['mobile_no']; // required | |
$email = $_POST['email']; // required | |
$mahram_name = $_POST['mahram_name']; // required | |
$mahram_relationship = $_POST['maharam_reltionship']; // required | |
$passport_no = $_POST['passport_no']; // required | |
$authority = $_POST['authority']; // required | |
$package = $_POST['package1']; | |
if (isset($package) && count($package) > 0) { | |
$package = implode(',', $package); | |
} else { | |
$package = ''; | |
} | |
$roomoccupancy = $_POST['roomoccupancy']; | |
if (isset($roomoccupancy) && count($roomoccupancy) > 0) { | |
$roomoccupancy = implode(',', $roomoccupancy); | |
} else { | |
$roomoccupancy = ''; | |
} | |
$contact1_fullName = $_POST['fullName1']; // required | |
$contact1_address = $_POST['contact1_address']; // required | |
$contact1_postal_code = $_POST['contact1_postal_code']; // required | |
$contact1_daytime_telephone = $_POST['conatact1_daytime_telephone']; // required | |
$contact1_mobile = $_POST['conatact1_mobile_no']; // required | |
$contact1_email = $_POST['contact1_email']; // required | |
$contact1_relation = $_POST['contact1_reltionship']; // required | |
$contact2_fullName = $_POST['fullName2']; // required | |
$contact2_address = $_POST['contact2_address']; // required | |
$contact2_postal_code = $_POST['contact2_postal_code']; // required | |
$contact2_mobile = $_POST['contact2_mobile_no']; // required | |
$contact2_daytime_telephone = $_POST['contact2_daytime_telephone']; // required | |
$contact2_email = $_POST['contact2_email']; // required | |
$contact2_relation = $_POST['contact2_reltionship']; // required | |
$first_price = $_POST['price']; // required | |
$date = $_POST['date']; // required | |
$second_price = $_POST['under_price']; // required | |
$attachments = array(); | |
move_uploaded_file($_FILES["sign"]["tmp_name"], WP_CONTENT_DIR . '/uploads/' . basename($_FILES['sign']['name'])); | |
array_push($attachments, WP_CONTENT_DIR . "/uploads/" . $_FILES["sign"]["name"]); | |
move_uploaded_file($_FILES["under_sign"]["tmp_name"], WP_CONTENT_DIR . '/uploads/' . basename($_FILES['under_sign']['name'])); | |
array_push($attachments, WP_CONTENT_DIR . "/uploads/" . $_FILES["under_sign"]["name"]); | |
$p_name = $_POST['p_name']; // required | |
$under_date = $_POST['under_date']; // required | |
$error_message = ""; | |
$email_exp = '/^[A-Za-z0-9._%-]+@[A-Za-z0-9.-]+\.[A-Za-z]{2,4}$/'; | |
if (!preg_match($email_exp, $email)) { | |
$error_message .= 'The Email Address you entered does not appear to be valid.<br />'; | |
} | |
$string_exp = "/^[A-Za-z .'-]+$/"; | |
if (!preg_match($string_exp, $first_name)) { | |
$error_message .= 'The First Name you entered does not appear to be valid.<br />'; | |
} | |
if (strlen($error_message) > 0) { | |
died($error_message); | |
} | |
$email_message = "Form details below.\n\n"; | |
function clean_string($string) | |
{ | |
$bad = array("content-type", "bcc:", "to:", "cc:", "href"); | |
return str_replace($bad, "", $string); | |
} | |
$email_message = "Hello Admin, You have got a new Application with following details: \n\n"; | |
$email_message .= "Title : " . clean_string($title) . "\n"; | |
$email_message .= "First Name : " . clean_string($first_name) . "\n"; | |
$email_message .= "Last Name : " . clean_string($last_name) . "\n"; | |
$email_message .= "Address one : " . clean_string($addressOne) . "\n"; | |
$email_message .= "Postal code : " . clean_string($postal_code) . "\n"; | |
$email_message .= "Email : " . clean_string($email) . "\n"; | |
$email_message .= "Daytime Telephone : " . clean_string($daytime_telephone) . "\n"; | |
$email_message .= "Mobile No : " . clean_string($mobile_no) . "\n"; | |
$email_message .= "Mahram Name : " . clean_string($mahram_name) . "\n"; | |
$email_message .= "Mahram Relationship : " . clean_string($mahram_relationship) . "\n"; | |
$email_message .= "Passport Nn : " . clean_string($passport_no) . "\n"; | |
$email_message .= "Authority : " . clean_string($authority) . "\n"; | |
$email_message .= "Package : " . clean_string($package) . "\n"; | |
$email_message .= "Room Occupancy : " . clean_string($roomoccupancy) . "\n"; | |
$email_message .= "Contact 1 Name : " . clean_string($contact1_fullName) . "\n"; | |
$email_message .= "Contact 1 Postal Code : " . clean_string($contact1_postal_code) . "\n"; | |
$email_message .= "Contact 1 Mobile: " . clean_string($contact1_mobile) . "\n"; | |
$email_message .= "Contact 1 Email: " . clean_string($contact1_email) . "\n"; | |
$email_message .= "Contact 1 Daytime Telephone: " . clean_string($contact1_daytime_telephone) . "\n"; | |
$email_message .= "Contact 1 Relationship: " . clean_string($contact1_relation) . "\n"; | |
$email_message .= "Contact 2 Name : " . clean_string($contact2_fullName) . "\n"; | |
$email_message .= "Contact 2 Postal Code : " . clean_string($contact2_postal_code) . "\n"; | |
$email_message .= "Contact 2 Mobile: " . clean_string($contact2_mobile) . "\n"; | |
$email_message .= "Contact 2 Email: " . clean_string($contact2_email) . "\n"; | |
$email_message .= "Contact 2 Daytime Telephone: " . clean_string($contact2_daytime_telephone) . "\n"; | |
$email_message .= "Contact 2 Relationship: " . clean_string($contact2_relation) . "\n"; | |
$email_message .= "Above 18 Price: " . clean_string($first_price) . "\n"; | |
$email_message .= "Above 18 Date: " . clean_string($date) . "\n"; | |
$email_message .= "Below 18 Price: " . clean_string($second_price) . "\n"; | |
$email_message .= "Print Name: " . clean_string($p_name) . "\n"; | |
$email_message .= "Below 18 date: " . clean_string($under_date) . "\n"; | |
$email_message .= "Thanks & Regards, \n" . $first_name . " " . $last_name; | |
$headers = "From: " . $email . "\r\n"; | |
$headers .= "Reply-To: " . $email . "\r\n"; | |
$headers .= "X-Mailer: PHP/" . phpversion(); | |
$headers .= "MIME-Version: 1.0" . "\r\n"; | |
$mail = wp_mail($email_to, $email_subject, $email_message, $headers, $attachments); | |
echo $mail ? "Thank you for connecting with us! We will contact you shortly!" : " Mail failed"; | |
} | |
?> | |
<!-- Main --> | |
<div class="clear"></div> | |
<div class="main" role="main"> | |
<!-- Slider --> | |
<?php /* <section class="slider-holder"> | |
<div class="flexslider carousel"> | |
<ul class="slides"> | |
<li class="flex-active-slide" style="width: 100%; float: left; margin-right: -100%; position: relative; display: block; z-index: 2; opacity: 1;"> <img src="<?php echo get_stylesheet_directory_uri();?>/images/slide2.jpg" alt="" draggable="false"> </li> | |
<!-- <li style="width: 100%; float: left; margin-right: -100%; position: relative; display: block; z-index: 1; opacity: 0;" class=""> <img src="<?php //echo get_template_directory_uri();?>/images/slide2.jpg" alt="" draggable="false"> </li> | |
<li style="width: 100%; float: left; margin-right: -100%; position: relative; display: block; z-index: 1; opacity: 0;" class=""> <img src="<?php //echo get_template_directory_uri();?>/images/slide3.jpg" alt="" draggable="false"> </li> --> | |
</ul> | |
<!-- <ol class="flex-control-nav flex-control-paging"> | |
<li><a class="flex-active">1</a></li> | |
<li><a class="">2</a></li> | |
<li><a class="">3</a></li> | |
</ol> --> | |
</div> | |
</section> */ ?> | |
<section class="page-heading"> | |
<div class="container"> | |
<div class="row"> | |
<div class="col-md-6"> | |
<h1><?php the_title(); ?></h1> | |
</div> | |
<div class="col-md-6"> | |
<?php if (have_posts()) : while (have_posts()) : the_post(); ?> | |
<?php the_content(); ?> | |
<?php endwhile; endif; ?> | |
</div> | |
</div> | |
</div> | |
</section> | |
<section class="page-content"> | |
<div class="container"> | |
<form id="regd_form" enctype="multipart/form-data" method="post" | |
action=""> | |
<div class="row"> | |
<div class="col-md-6"> | |
<label> | |
<p><b>Personal Details :</b></p><br> | |
</label> | |
</div> | |
<div class="col-md-6"> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label class="control-label" for="title">Title</label> | |
</div> | |
</div> | |
<div class="col-md-6"> | |
<div class="form-group"> | |
<label class="checkbox-inline"> | |
<input type="checkbox" name="title[]" value="Dr"> | |
Dr | |
</label> | |
<label class="checkbox-inline"> | |
<input type="checkbox" name="title[]" value="Mr"> | |
Mr | |
</label> | |
<label class="checkbox-inline"> | |
<input type="checkbox" name="title[]" value="Mrs"> | |
Mrs | |
</label> | |
<label class="checkbox-inline"> | |
<input type="checkbox" name="title[]" value="Miss"> | |
Miss | |
</label> | |
<label class="checkbox-inline"> | |
<input type="checkbox" name="title[]" value="Ms"> | |
Ms | |
</label> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Forenames | |
</label> | |
</div> | |
</div> | |
<div class="col-md-9"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="fore_name" id="fore_name"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Surname | |
</label> | |
</div> | |
</div> | |
<div class="col-md-9"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="sur_name" id="sur_name"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Address 1 | |
</label> | |
</div> | |
</div> | |
<div class="col-md-9"> | |
<div class="form-group"> | |
<!-- <input type="text" class="form-control" name="address_1" id="address_1">--> | |
<textarea rows="4" cols="77" name="address_1" style="width: 100%"></textarea> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Postal Code | |
</label> | |
</div> | |
</div> | |
<div class="col-md-9"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="postal_code" id="postal_code"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Daytime Telephone | |
</label> | |
</div> | |
</div> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="daytime_telephone" id="daytime_telephone"> | |
</div> | |
</div> | |
<div class="col-md-1"> | |
<div class="form-group"> | |
<label> | |
Mobile | |
</label> | |
</div> | |
</div> | |
<div class="col-md-5"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="mobile_no" id="mobile_no"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
</label> | |
</div> | |
</div> | |
<div class="col-md-9"> | |
<div class="form-group"> | |
<input type="email" class="form-control" name="email" id="email"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Mahram's Name<br> | |
( Female's Only ) | |
</label> | |
</div> | |
</div> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="mahram_name" id="mahram_name"> | |
</div> | |
</div> | |
<div class="col-md-1"> | |
<div class="form-group"> | |
<label> | |
Relation of ( Mahram ) | |
</label> | |
</div> | |
</div> | |
<div class="col-md-5"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="maharam_reltionship" id="maharam_reltionship"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Passport number | |
</label> | |
</div> | |
</div> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="passport_no" id="passport_no"> | |
</div> | |
</div> | |
<div class="col-md-1"> | |
<div class="form-group"> | |
<label> | |
Authority | |
</label> | |
</div> | |
</div> | |
<div class="col-md-5"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="authority" id="authority"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label class="control-label" for="package1">Package</label> | |
</div> | |
</div> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label class="checkbox-inline"> | |
<input type="checkbox" name="package1[]" value="2week"> | |
2 week | |
</label> | |
<label class="checkbox-inline"> | |
<input type="checkbox" name="package1[]" value="3week"> | |
3 week | |
</label> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3" id="type_of_business"> | |
<div class="form-group"> | |
<div class="form-group"> | |
<label class="control-label" for="roomoccupancy">Room occupancy</label> | |
</div> | |
</div> | |
</div> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label class="checkbox-inline"> | |
<input type="checkbox" name="roomoccupancy[]" value="Double"> | |
Double | |
</label> | |
<label class="checkbox-inline"> | |
<input type="checkbox" name="roomoccupancy[]" value="Triple"> | |
Triple | |
</label> | |
<label class="checkbox-inline"> | |
<input type="checkbox" name="roomoccupancy[]" value="Quadruple"> | |
Quadruple | |
</label> | |
</div> | |
</div> | |
</div> | |
<!--//=======================================================contact details (1)=========================================================================//--> | |
<div class="row"> | |
<div class="col-md-6 upload-form"> | |
<div class="form-group"> | |
<p><b> Emergency Contact Details</b></p> | |
<p>In case of an emergency please provide contact details:</p> | |
<p><b>Contact (1)</b></p> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Full Name | |
</label> | |
</div> | |
</div> | |
<div class="col-md-9"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="fullName1" id="fullName1"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Address | |
</label> | |
</div> | |
</div> | |
<div class="col-md-9"> | |
<div class="form-group"> | |
<!-- <input type="text" class="form-control" name="address_1" id="address_1">--> | |
<textarea rows="4" cols="77" name="contact1_address" style="width: 100%"></textarea> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Postal Code | |
</label> | |
</div> | |
</div> | |
<div class="col-md-9"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="contact1_postal_code" | |
id="contact1_postal_code"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Daytime Telephone | |
</label> | |
</div> | |
</div> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="conatact1_daytime_telephone" | |
id="conatact1_daytime_telephone"> | |
</div> | |
</div> | |
<div class="col-md-1"> | |
<div class="form-group"> | |
<label> | |
Mobile | |
</label> | |
</div> | |
</div> | |
<div class="col-md-5"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="conatact1_mobile_no" id="conatact1_mobile_no"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
</label> | |
</div> | |
</div> | |
<div class="col-md-9"> | |
<div class="form-group"> | |
<input type="email" class="form-control" name="contact1_email" id="contact1_email"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Relation | |
</label> | |
</div> | |
</div> | |
<div class="col-md-9"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="contact1_reltionship" | |
id="contact1_reltionship"> | |
</div> | |
</div> | |
</div> | |
<!--//=======================================================end contact detailsvc(1)================================================================//--> | |
<!--//=======================================================contact details (2)=========================================================================//--> | |
<div class="row"> | |
<div class="col-md-6 upload-form"> | |
<div class="form-group"> | |
<p><b>Contact (2)</b></p> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Full Name | |
</label> | |
</div> | |
</div> | |
<div class="col-md-9"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="fullName2" id="fullName2"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Address | |
</label> | |
</div> | |
</div> | |
<div class="col-md-9"> | |
<div class="form-group"> | |
<!-- <input type="text" class="form-control" name="address_1" id="address_1">--> | |
<textarea rows="4" cols="77" name=contact2_address" style="width: 100%"></textarea> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Postal Code | |
</label> | |
</div> | |
</div> | |
<div class="col-md-9"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="contact2_postal_code" | |
id="contact2_postal_code"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Daytime Telephone | |
</label> | |
</div> | |
</div> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="contact2_daytime_telephone" | |
id="contact2_daytime_telephone"> | |
</div> | |
</div> | |
<div class="col-md-1"> | |
<div class="form-group"> | |
<label> | |
Mobile | |
</label> | |
</div> | |
</div> | |
<div class="col-md-5"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="contact2_mobile_no" id="contact2_mobile_no"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
</label> | |
</div> | |
</div> | |
<div class="col-md-9"> | |
<div class="form-group"> | |
<input type="email" class="form-control" name="contact2_email" id="contact2_email"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Relation | |
</label> | |
</div> | |
</div> | |
<div class="col-md-9"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="contact2_reltionship" | |
id="contact2_reltionship"> | |
</div> | |
</div> | |
</div> | |
<!--//=======================end contact detailsvc(2)==================================================//--> | |
<div class="row"> | |
<div class="col-md-12"> | |
<div class="form-group"> | |
<label> | |
<p><b>Declaration</b></p> | |
<p> I declare that all the information on this booking form is correct to the best of my | |
knowledge. I accept and abide by the booking terms and conditions, available at | |
www.hajjltd.com/terms, which I have read and understood.</p> | |
</label> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
I have paid a deposit of | |
</label> | |
</div> | |
</div> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="price" id="price"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-4"> | |
<div class="form-group"> | |
<label> | |
<p><b>Please attach the following with this application:</b></p> | |
</label> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
</div> | |
</div> | |
<div class="col-md-7"> | |
<div class="form-group"> | |
<label> | |
<br> | |
<ul style="list-style-type: square;"> | |
<li><p> Copy of your Passport (valid for at least 6 months from the date of | |
departure).</p></li> | |
<li><p> 2 passport sized photos with your name printed at the back of each | |
photo. </p></li> | |
</ul> | |
</label> | |
<label> | |
<br> | |
<p><b>Please Note:</b>Pilgrim must not have travelled to perform Hajj within the past 5 | |
years (to attach old passport) Birth Certificates/Marriage certificates need to be | |
submitted with passports as proof of relationship status for | |
women/children with a Mahram</p> | |
</label> | |
</div> | |
</div> | |
<div class="col-md-2"> | |
<div class="form-group"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Signature : | |
</label> | |
</div> | |
</div> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<input type="file" class="form-control" name="sign" id="sign"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Date: | |
</label> | |
</div> | |
</div> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<input type="date" class="form-control" name="date" id="date"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-12"> | |
<div class="form-group"> | |
<label> | |
<p><b>For applicants under 18 years of age:</b></p> | |
<p>I declare as the parent/ guardian of the child named on this booking form, take full | |
responsibility that the information I provided is correct to the best of my | |
knowledge. I accept and abide by the booking terms and conditions, available at | |
www.hajjltd.com/terms, which I have read and understood.</p> | |
</label> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
I have paid a deposit of | |
</label> | |
</div> | |
</div> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="under_price" id="price"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-4"> | |
<div class="form-group"> | |
<label> | |
<p><b>Please attach the following with this application:</b></p> | |
</label> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
</div> | |
</div> | |
<div class="col-md-7"> | |
<div class="form-group"> | |
<label> | |
<br> | |
<ul style="list-style-type: square;"> | |
<li><p> Copy of the Childs Passport.</p></li> | |
<li><p> 2 passport sized photos with the name printed at the back of each | |
photo. </p></li> | |
</ul> | |
</label> | |
<label> | |
<br> | |
<p><b>Please Note:</b>Pilgrim must not have travelled to perform Hajj within the past 5 | |
years (to attach old passport) Birth Certificates/Marriage certificates need to be | |
submitted with passports as proof of relationship status for | |
women/children with a Mahram</p> | |
</label> | |
</div> | |
</div> | |
<div class="col-md-2"> | |
<div class="form-group"> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Signature : | |
</label> | |
</div> | |
</div> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<input type="file" class="form-control" name="under_sign" id="sign"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Print Name: | |
</label> | |
</div> | |
</div> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<input type="text" class="form-control" name="p_name" id="p_name"> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<label> | |
Date: | |
</label> | |
</div> | |
</div> | |
<div class="col-md-3"> | |
<div class="form-group"> | |
<input type="date" class="form-control" name="under_date" id="date"> | |
</div> | |
</div> | |
</div> | |
</div> | |
<div class="row"> | |
<div class="col-md-6"><input type="submit" name="submit" value="Submit" id="submit" | |
class="btn btn-primary" style="margin-left: 376px;"></div> | |
<div class="col-md-6"><input type="button" | |
onclick="window.location.href='http://178.62.55.80/hajjltd/'" | |
name="button" value="Back" id="reset1" | |
class="btn btn-primary" style="margin-left: 470px;"></div> | |
</div> | |
</form> | |
</div> | |
</section> | |
<div class="clear"></div> | |
<?php get_footer(); ?> |
Sign up for free
to join this conversation on GitHub.
Already have an account?
Sign in to comment