113 lines
4.4 KiB
PHP
Executable File
113 lines
4.4 KiB
PHP
Executable File
<?php
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/* @var $this yii\web\View */
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use kartik\date\DatePicker;
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use kartik\datetime\DateTimePicker;
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use yii\captcha\Captcha;
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use yii\helpers\Html;
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use yii\bootstrap4\ActiveForm;
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use yii\widgets\MaskedInput;
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$this->title = 'แจ้งแบบคำร้องเบี้ยยังชีพผู้สูงอายุ';
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$this->params['breadcrumbs'][] = $this->title;
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?>
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<!-- css -->
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<link rel="stylesheet" href="https://use.fontawesome.com/releases/v5.3.1/css/all.css">
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<div class="card shadow">
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<div class="card-body">
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<h5 class="text-center">ท่านสามารถแจ้ง<?= $this->title ?> ถึง <?= Yii::$app->params['org_name_th'] ?>ได้โดย</h5>
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<style>
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.link-a a {
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color: #3d9970;
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}
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.link-a a:hover {
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color: #007bff;
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}
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.link-a li{
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list-style: list;
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}
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</style>
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<ol class="link-a">
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<li><?= $this->title ?>ถึง <?= Yii::$app->params['org_name_th'] ?> <?= Yii::$app->params['org_place2'] ?></li>
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<li>ส่งเรื่อง<?= $this->title ?> มายัง Facebook <?=Html::a(Yii::$app->params['org_name_th'], Yii::$app->params['org_face'])?></li>
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<li>ทางโทรศัพท์ <?= Yii::$app->params['org_phone'] ?> (วันและเวลาราชการ 08.30 - 16.30 น.)</li>
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<li>ผ่านทางเว็บไซต์ของ<?=Html::a(Yii::$app->params['org_name_th'], Yii::$app->params['org_web'])?> โดยกรอกข้อมูลในแบบฟอร์มด้านล่าง</li>
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</ol>
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<div class="oldage-form">
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<?php $form = ActiveForm::begin(); ?>
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<?= $form->errorSummary($model) ?>
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<div class="row">
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<div class="col-md-2"><?= $form->field($model, 'title')->dropDownList(['นาย' => 'นาย', 'นาง' => 'นาง', 'นางสาว' => 'นางสาว', 'อื่นๆ' => 'อื่นๆ']) ?></div>
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<div class="col-md-5"><?= $form->field($model, 'name') ?></div>
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<div class="col-md-5">
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<?= $form->field($model, 'id_card')->widget(
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MaskedInput::class, [
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'mask' => '9-9999-99999-99-9'
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]) ?>
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</div>
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</div>
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<div class="row">
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<div class="col-md-3"><?= $form->field($model, 'bdate')->widget(DatePicker::class, [
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'name' => 'bdate',
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'options' => ['placeholder' => 'วัน/เดือน/ปีเกิด'],
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'pluginOptions' => [
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'language' => 'th',
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'autoclose' => true,
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]
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]) ?>
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</div>
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</div>
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<div class="row">
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<div class="col-md-2"><?= $form->field($model, 'nation')->textInput() ?></div>
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</div>
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<div class="row">
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<div class="col-md-2"><?= $form->field($model, 'regishouse')->textInput() ?></div>
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</div>
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<div class="row">
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<div class="col-md-2">
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<?= $form->field($model, 'tel')->widget(MaskedInput::class, [
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'mask' => '999-999-9999'
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]) ?>
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</div>
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</div>
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<?= $form->field($model, 'address')->textarea(['rows' => 6]) ?>
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<?= $form->field($model, 'card_copy')->fileInput() ?>
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<?= $form->field($model, 'add_copy')->fileInput() ?>
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<?= $form->field($model, 'bank_copy')->fileInput() ?>
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<?= $form->field($model, 'process')->radioList([1 => 'ยอมรับ']) ?>
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<?= $form->field($model, 'verifyCode')->label(false)->widget(Captcha::className(), [
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'template' => '<div class="row"><div class="col-lg-2">{image}</div><div class="col-lg-6">{input}</div></div>',
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]) ?>
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<div class="form-group" style="text-align: center">
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<?= Html::submitButton('<span class="fa fa-save"></span> ส่งข้อมูล', ['class' => 'btn btn-success']) ?>
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</div>
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<?php ActiveForm::end(); ?>
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</div>
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</div>
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</div>
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