ꦫꦣꦺꦤ꧀ꦄꦤ꧀ꦠꦱꦺꦤ

PATH: home / lab2454c / healthvalidate.com / resources / views / corporate

@extends('layouts.corporate.application')
@section('content')

<h2>Business Application</h2>
<div class="form__wrapp register__form__wrapp">
    @include('validation.message')
    @include('validation.flashmessage')
    <form method="POST" action="{{ route('corporate.application') }}">
        @csrf
        <div class="form-group form__group">
            <input type="text" name="organization_name" value="{{ old('organization_name') }}" class="form-control form__control"
                placeholder="Organization Name" required>
        </div>
        <div class="form-group form__group">
            <label>Industry Type</label>
            <select name="industry_type" class="form-control form__control selectpicker corporate__industry_type" data-live-search="true">
                <option value="health-care-biotech" @if(old("industry_type")=='health-care-biotech'){{'selected="selected"'}}@endif>Health Care &amp; Biotech</option>
                
                <option value="education" @if(old("industry_type")=='education'){{'selected="selected"'}}@endif>Education</option>
                
                <option value="software-technology" @if(old("industry_type")=='software-technology'){{'selected="selected"'}}@endif>Software and Technology</option>
                
                <option value="consulting-professional-business-services" @if(old("industry_type")=='consulting-professional-business-services'){{'selected="selected"'}}@endif>Consulting, Professional &amp; Business Services</option>
                
                <option value="banking-insurance-financial-services" @if(old("industry_type")=='banking-insurance-financial-services'){{'selected="selected"'}}@endif>Banking/ Insurance/ Financial Services</option>
                
                <option value="government" @if(old("industry_type")=='government'){{'selected="selected"'}}@endif>Government</option>
                
                <option value="legal" @if(old("industry_type")=='legal'){{'selected="selected"'}}@endif>Legal</option>
                
                <option value="energy-utilities" @if(old("industry_type")=='energy-utilities'){{'selected="selected"'}}@endif>Energy/Utilities</option>
                
                <option value="non-for-profit" @if(old("industry_type")=='non-for-profit'){{'selected="selected"'}}@endif>Non For Profit</option>
                
                <option value="food-beverage" @if(old("industry_type")=='food-beverage'){{'selected="selected"'}}@endif>Food &amp; Beverage</option>
                
                <option value="other" @if(old("industry_type")=='other'){{'selected="selected"'}}@endif>Other</option>
                
            </select>
        </div>
        
        <div class="form-group form__group industry_type_other_wrap" style=@if(old('industry_type') == 'other'){{'display:block;'}}@else{{'display:none;'}}@endif>
            <input type="text" name="industry_type_other" value="{{ old('industry_type_other') }}" class="form-control form__control industry_type_other" placeholder="Enter Industry Type" @if(old('industry_type') == 'other'){{'required'}}@endif>
        </div>
        
        <div class="form-group form__group">
            <input type="text" name="registration_no" value="{{ old('registration_no') }}" class="form-control form__control"
                placeholder="Organization Registration (FEIN)" required>
        </div>
        
        
        
       
        <div class="form-group form__group">
            <label>Organization Size</label>
            <select name="industry_size" class="form-control form__control selectpicker" data-live-search="true">
                <option value="1-19" @if(old("industry_size")=='1-19'){{'selected="selected"'}}@endif>1 - 19 employees</option>
                
                <option value="20-99" @if(old("industry_size")=='20-99'){{'selected="selected"'}}@endif>20 - 99 employees</option>
                
                <option value="100-499" @if(old("industry_size")=='100-499'){{'selected="selected"'}}@endif>100 - 499 employees</option>
                
                <option value="500-999" @if(old("industry_size")=='500-999'){{'selected="selected"'}}@endif>500 - 999 employees</option>
                
                <option value="1000-5000" @if(old("industry_size")=='1000-5000'){{'selected="selected"'}}@endif>1,000 - 5,000 employees</option>
                
                <option value="5000+" @if(old("industry_size")=='5000+'){{'selected="selected"'}}@endif>5,000+ employees</option>                
            </select>
        </div>
        
        
        <div class="form-group form__group">
            <div class="row">
                <div class="col-6">
                    <input type="text" name="first_name" value="{{ old('first_name') }}" class="form-control form__control" placeholder="Contact First Name" required>
                </div>
                <div class="col-6">
                    <input type="text" name="last_name" value="{{ old('last_name') }}" class="form-control form__control" placeholder="Contact Last Name" required>
                </div>
            </div>
        </div>
        
        <div class="form-group form__group">
            <input type="email" name="email" value="{{ old('email') }}" class="form-control form__control"
                placeholder="Contact Email" required>
        </div>
        
    
        <div class="form-group form__group">
            <input type="tel" name="phone" value="{{ old('phone') }}" class="form-control form__control"
                placeholder="Contact No." required>
        </div>
        
        <div class="form-group form__group">
            <input type="text" name="department" value="{{ old('department') }}" class="form-control form__control"
                placeholder="Contact Department" required>
        </div>
        
        <div class="form-group form__group">
            <input type="text" name="contact_title" value="{{ old('contact_title') }}" class="form-control form__control"
                placeholder="Contact Title" required>
        </div>
        
        <div class="form__wrapp__bottom">
            <input type="submit" name="submit" value="Submit" class="submit__btn">
        </div>
    </form>
</div>

@endsection

[+] ..
[-] application.blade.php [edit]