@extends('layouts.front_layout') @section('content')

New Complaint ( Vigilance ) Registration

Please Wait...

{!! Form::open(['method' => 'POST', 'route' => ['submit_complaint'], 'files' => 'true', 'id' => 'signUpForm']) !!}
Your Personal Details Identity Details Contact Details Complaint Details

Your Personal Details

{!! Form::text('first_name', null, ['class' => 'form-control', 'required'=>"true", 'alphanumeric' => 'true']) !!}
{!! Form::text('middle_name', null, ['class' => 'form-control']) !!}
{!! Form::text('last_name', null, ['class' => 'form-control', 'required'=>"true", 'alphanumeric' => 'true']) !!}
{!! Form::select('gender', gender_list(), null, ['class' => 'form-select', 'required'=>"true"]) !!}
{!! Form::date('dob', null, ['class' => 'form-control', 'max' => date('Y-m-d'), 'required'=>"true"]) !!} {{ $errors->first('dob') }}
@if ($errors->has('g-recaptcha-response')) {{ $errors->first('g-recaptcha-response') }} @endif

Identity Details

{!! Form::select('id_type', id_type_list(), null, ['class' => 'form-select', 'required'=>"true"]) !!}
{!! Form::text('id_number', null, ['class' => 'form-control uppercase', 'required'=>"true"]) !!}

Contact Details

{!! Form::email('email_id', null, ['class' => 'form-control', 'pattern' => '^([a-zA-Z0-9_\-\.]+)@((\[[0-9]{1,3}\.[0-9]{1,3}\.[0-9]{1,3}\.)|(([a-zA-Z0-9\-]+\.)+))([a-zA-Z]{2,4}|[0-9]{1,3})(\]?)$']) !!}
{!! Form::text('landline_no', null, ['class' => 'form-control']) !!}
{!! Form::text('mobile_no', null, ['class' => 'form-control only_numbers', 'required'=>"true"]) !!}
{!! Form::text('address_line1', null, ['class' => 'form-control']) !!}
{!! Form::text('address_line2', null, ['class' => 'form-control']) !!}
{!! Form::text('address_line3', null, ['class' => 'form-control']) !!}
{!! Form::select('state_id', $state_list, null, ['class' => 'form-select', 'placeholder' => 'Select State', 'onchange' => 'getDistrictListbyStateId(this)', 'required'=>"true"]) !!}
{!! Form::select('district_id', array(), null, ['class' => 'form-select', 'placeholder' => 'Select District', 'id' => 'district_list', 'onchange' => 'getCityListbyDistrictId(this)', 'required'=>"true"]) !!} {{ $errors->first('district_id') }}
{!! Form::text('pincode', null, ['class' => 'form-control only_numbers', 'required'=>"true"]) !!}
{!! Form::select('city_id', array(), null, ['class' => 'form-select', 'placeholder' => 'Select City', 'id' => 'city_list', 'required'=>"true", 'onchange' => 'addnewcity(this)']) !!} {{ $errors->first('city_id') }}

Complaint Details

{!! Form::select('determinationof_vigilance_angle_id', $determinationofvigilanceangle_list, null, ['class' => 'form-select', 'placeholder' => 'Select', 'required'=>"true"]) !!}
(.pdf only)(Max. File size 3MB)
{!! Form::textarea('complaint_description', null, ['class' => 'form-control', 'rows' => 2, 'maxlength' => "3000", 'required'=>"true"]) !!}
{!! Form::textarea('remarks', null, ['class' => 'form-control', 'maxlength' => "3000", 'rows' => 2]) !!}
{!! Form::close() !!}
@endsection