| Server IP : 162.214.74.102 / Your IP : 216.73.216.59 Web Server : Apache System : Linux dedi-4363141.lrsys.com.br 3.10.0-1160.119.1.el7.tuxcare.els25.x86_64 #1 SMP Wed Oct 1 17:37:27 UTC 2025 x86_64 User : lrsys ( 1015) PHP Version : 5.6.40 Disable Function : exec,passthru,shell_exec,system MySQL : ON | cURL : ON | WGET : ON | Perl : ON | Python : ON | Sudo : ON | Pkexec : ON Directory : /home/lrsys/www/lrsys_projetos/sopizzas/application/views/frontend/ |
Upload File : |
</div>
</section>
<div class="for-fixed"></div>
<section id="driver-license mctop75" style="">
<div class="container">
<div class="row driver-lice">
<div class="col-md-12 col-sm-12 col-xs-12">
<h2 class="text-center">Driver's License</h2>
<p class="text-center">Enter your name as it appears on your Driver's License<br>You must have a valid license - we do not accept other forms of ID.</p>
<?php if($this->session->flashdata('success_msg')) { ?>
<div class="alert alert-info text-center">
<a href="#" class="close" data-dismiss="alert" aria-label="close">×</a>
<strong><?php echo $this->session->flashdata('success_msg'); ?></strong>
</div>
<?php } ?>
<?php if($this->session->flashdata('error_msg')) { ?>
<div class="alert alert-danger text-center">
<a href="#" class="close" data-dismiss="alert" aria-label="close">×</a>
<strong><?php echo $this->session->flashdata('error_msg'); ?></strong>
</div>
<?php } ?>
<?php if(validation_errors() != FALSE) { ?>
<div class="alert alert-danger text-center">
<a href="#" class="close" data-dismiss="alert" aria-label="close">×</a>
<strong><?php echo validation_errors(); ?></strong>
</div>
<?php } ?>
<?php $validator = array('role' => 'form', 'data-toggle' => 'validator'); echo form_open('applydriveronline', $validator); ?>
<div class="col-md-3">
<div class="form-group">
<input type="text" class="form-control" id="driver_license_first_name" name="driver_license_first_name" placeholder="First Name" value="<?=set_value('driver_license_first_name', isset($driver_details['driver_first_name'])?$driver_details['driver_first_name']:'')?>" required data-error="Please enter your first name">
<div class="help-block with-errors"></div>
</div>
</div>
<div class="col-md-3">
<div class="form-group">
<input type="text" class="form-control" id="driver_license_middle_name" name="driver_license_middle_name" placeholder="Middle Name" value="<?=set_value('driver_license_middle_name', isset($driver_details['driver_middle_name'])?$driver_details['driver_middle_name']:'')?>">
<div class="help-block with-errors"></div>
</div>
</div>
<div class="col-md-3">
<div class="form-group">
<input type="text" class="form-control" id="driver_license_last_name" name="driver_license_last_name" placeholder="Last Name" value="<?=set_value('driver_license_last_name', isset($driver_details['driver_last_name'])?$driver_details['driver_last_name']:'')?>" required data-error="Please enter your last name">
<div class="help-block with-errors"></div>
</div>
</div>
<div class="col-md-3">
<div class="form-group">
<div class="input-group">
<input onkeypress="return only_num(event, this.value)" type="text" class="form-control" id="driver_license_dob" name="driver_license_dob" placeholder="Birth Date" required data-error="Please enter date of birth as in license" value="<?=set_value('driver_license_dob')?>">
<span class="input-group-btn">
<button class="btn btn-default dobed" type="button"><i class="fa fa-calendar-o" aria-hidden="true"></i></button>
</span>
</div>
</div>
<div class="help-block with-errors"></div>
</div>
<div class="col-md-3">
<div class="form-group">
<input type="text" class="form-control" id="driver_license_number" name="driver_license_number" placeholder="Driver License Number" <?=$driver_details['driver_vehicle_make'] == "Bicycle" ? "" : "required"?> data-error="Please enter license number" value="<?=set_value('driver_license_number')?>">
<div class="help-block with-errors"></div>
</div>
</div>
<div class="col-md-3">
<div class="form-group">
<div class="input-group">
<input onkeypress="return only_num(event, this.value)" type="text" class="form-control" id="driver_license_expire_dob" name="driver_license_expire_dob" placeholder="DL Expiration Date" <?=($vehicle_type == "Bicycle" ? "" : "required")?> data-error="Please enter license expire date" value="<?=set_value('driver_license_expire_dob')?>">
<span class="input-group-btn">
<button class="btn btn-default dobed" type="button"><i class="fa fa-calendar-o" aria-hidden="true"></i></button>
</span>
</div>
</div>
<div class="help-block with-errors"></div>
</div>
<div class="col-md-3">
<div class="form-group">
<input type="text" class="form-control" id="driver_license_plate_number" name="driver_license_plate_number" placeholder="License Plate Number" <?=$driver_details['driver_vehicle_make'] == "Bicycle" ? "" : "required"?> data-error="Please enter license plate number" value="<?=set_value('driver_license_plate_number')?>">
<div class="help-block with-errors"></div>
</div>
</div>
<div class="col-md-3">
<div class="form-group">
<!-- <select class="form-control" id="driver_license_state" name="driver_license_state" required data-error="Please choose state as in license">
<option value="">Select State</option>
<?php
$state = set_value('driver_license_state', isset($driver_details['driver_state'])?$driver_details['driver_state']:'');
foreach ($StateList as $key => $value) {
?>
<option value="<?=$value->statecode?>" <?=$state==$value?'selected':''?> ><?=$value->statename?></option>
<?php
}
?>
</select> -->
<input type="text" class="form-control" id="driver_license_state" name="driver_license_state" value="<?=set_value('driver_license_state', isset($driver_details['driver_state'])?$driver_details['driver_state']:'')?>">
<div class="help-block with-errors"></div>
</div>
</div>
<div class="clearfix"></div>
<div class="col-md-12">
<h3 class="title-bod">Insurance Information:</h3>
</div>
<div class="col-md-6">
<div class="form-group">
<input type="text" class="form-control" id="driver_insurance_provider" name="driver_insurance_provider" placeholder="Insurance Provider" <?=$driver_details['driver_vehicle_make'] == "Bicycle" ? "" : "required"?> data-error="Please enter insurance provider name" value="<?=set_value('driver_insurance_provider')?>">
<div class="help-block with-errors"></div>
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<input type="text" class="form-control" id="driver_insurance_number" name="driver_insurance_number" placeholder="Insurance Policy Number" <?=$driver_details['driver_vehicle_make'] == "Bicycle" ? "" : "required"?> data-error="Please enter insurance number" value="<?=set_value('driver_insurance_number')?>">
<div class="help-block with-errors"></div>
</div>
</div>
<div class="col-md-12">
<div class="form-group">
<div class="" style="padding-left: 0px;">
<label>
<input type="checkbox" name="is_vehicle_certify" id="is_vehicle_certify" data-error="Please check this box to forward" required="">
By checking this box, you certify that you have valid and current vehicle insurance.
</label>
</div>
</div>
</div>
<div class="clearfix"></div>
<div class="col-md-12">
<input type="hidden" name="form_name" value="driver_apply_license">
<input type="hidden" name="driver_id" value="<?=isset($driver_id)?$driver_id:''?>">
<button type="submit" class="btn btn-info nxt-btn">Next</button>
<button type="button" onclick="window.location.href='<?=base_url();?>applydriveronline/details'" class="btn btn-link pull-right"><i class="fa fa-arrow-left" aria-hidden="true"></i> Back</button>
</div>
</form>
</div>
</div>
</div>
</section>
<style type="text/css">
.help-block.with-errors {
min-height: 20px;
}
</style>
<style type="text/css">
.form-control[disabled], .form-control[readonly], fieldset[disabled] .form-control {
background-color: #FFF;
}
</style>