@extends('frontend.layouts.landing') @section('title', 'Get Your Free Pet Badge - ' . app_name()) @php $url = URL::current(); @endphp @push('head-area') @endpush @section('content')

Get Your Free Pet Badge

@include('includes.partials.messages') {!! Form::open(array('route' => $data['route'], 'method' => 'POST', 'id' => 'frm_pet_badge3', 'files' => true)) !!}
@if($data['ses_data']['hd_already_exists'] == 'Y' && $data['ses_data']['additional'] == 'Y') @endif
Email Address {{ $data['ses_data']['email'] }}
First Name {{ $data['ses_data']['first_name'] }}
Last Name {{ $data['ses_data']['last_name'] }}
Company/Institute {{ $data['ses_data']['company'] }}
Phone {{ $data['ses_data']['phone'] }}
Address {{ $data['ses_data']['address'] }}
City {{ $data['ses_data']['city'] }}
State {{ $data['ses_data']['state'] }}
Zip Code {{ $data['ses_data']['zip'] }}
Printing Charges $5.99
@if($data['ses_data']['hd_already_exists'] == 'Y' && $data['ses_data']['additional'] == 'Y')
{!! Form::checkbox('same_billing_info_badges', 'Y', false, ['id' => 'same_billing_info_badges']) !!}
{!! Form::label('email', 'Email Address: *') !!} {!! Form::text('email', null, ['required' => 'required', 'type' => 'email', 'class' => 'form-control', 'placeholder' => 'Enter email address ...', 'id' => 'bl_email']) !!}
{!! Form::label('first_name', 'First Name: *') !!} {!! Form::text('first_name', null,['required' => 'required', 'class'=>'form-control', 'placeholder'=>'Enter first name ...', 'id' => 'bl_first_name']) !!}
{!! Form::label('last_name', 'Last Name: *') !!} {!! Form::text('last_name', null,['required' => 'required', 'class'=>'form-control', 'placeholder'=>'Enter last name ...', 'id' => 'bl_last_name']) !!}
{!! Form::label('company', 'Company:') !!} {!! Form::text('company', null,['class'=>'form-control', 'placeholder'=>'Enter company name ...', 'id' => 'bl_company', 'maxlength' => 50]) !!}
{!! Form::text('address', null,['required' => 'required', 'class'=>'form-control', 'placeholder'=>'Enter address ...', 'id' => 'bl_address']) !!}
{!! Form::label('state', 'State: *') !!}
{!! Form::select('state', $data['states'] ,@$data['ses_data_1']['state'] ,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Please Select ...']) !!}
{!! Form::label('city', 'City: *') !!} {!! Form::text('city', null,['required' => 'required', 'class'=>'form-control', 'placeholder'=>'Enter city ...', 'id' => 'bl_city']) !!}
{!! Form::label('zip', 'Zip / Post Code: *') !!} {!! Form::text('zip', null,['required' => 'required', 'maxlength' => '9', 'class'=>'form-control', 'placeholder'=>'Enter zip / post code ...', 'id' => 'bl_zip']) !!}
{!! Form::label('phone', 'Phone: *') !!} {!! Form::text('phone', null,['required' => 'required', 'class'=>'form-control', 'placeholder'=>'Enter phone ...', 'id' => 'bl_phone']) !!}
{!! Form::label('cc_number', 'Card Number:') !!}
{!! Form::text('cc_number', null, ['required' => 'required', 'class' => 'form-control', 'placeholder' => 'Card Number ...', 'id' => 'cc_number']) !!}
{!! Form::hidden('cc_type', null, ['id' => 'cc_type']) !!}
{!! Form::label('cc_month', 'Expiry Month:') !!} {!! Form::select('cc_month', $data['months'], null, ['required' => 'required', 'class'=>'form-control', 'placeholder'=>'Please Select ...']) !!}
{!! Form::label('cc_year', 'Expiry Year:') !!} {!! Form::select('cc_year', $data['years'], null, ['required' => 'required', 'class'=>'form-control', 'placeholder'=>'Please Select ...']) !!}
{!! Form::label('cc_cvv', 'CVC:') !!} {!! Form::text('cc_cvv', null,['required' => 'required', 'class'=>'form-control', 'placeholder'=>'Enter CVC ...', 'maxlength' => 4]) !!}
{!! Form::checkbox('terms', true, null, ['id' => 'terms']) !!}

Secure Payments by Authorize.net
@else @endif
{!! Form::close() !!}
@push('after-scripts') @endpush @endsection