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							<h1 class="black text-center">Residential Application</h1>
							<p class="text-center">
								Please follow the steps below to complete your application. We will get back to you shortly.
							</p>
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																<li style="width: 25%;"><a href="#address" class="nf-breadcrumb" data-toggle="tab" data-index="0" aria-expanded="true">Installation Address</a></li>
																<li class="active" style="width: 25%;"><a href="#information" class="nf-breadcrumb" data-toggle="tab" data-index="1">Application Information</a></li>
																<li style="width: 25%;"><a href="#service" class="nf-breadcrumb" data-toggle="tab" data-index="2">Service and Package Details</a></li>
																<li style="width: 25%;"><a href="#signaturess" class="nf-breadcrumb" data-toggle="tab" data-index="3">Preview</a></li>
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													@foreach($data as $d)
													<form action="{{url('/residential/'.$d['package'].'/application-form/service_package/'.$d['dealer_id'])}}" method="post" enctype="multipart/form-data" name="registerForm" novalidate="novalidate">

														<input type="hidden" name="_token" value="<?php echo csrf_token(); ?>">
														<input type="hidden" name="dealer_id" value="{{ $d['dealer_id'] }}">

														<!-- Input from previous form: step 1 -->
														
														<input type="hidden" name="coverage" value="{{ $d['coverage'] }}">
														<input type="hidden" name="unit" value="{{ $d['unit'] }}">
														<input type="hidden" name="street" value="{{ $d['street'] }}">
														<input type="hidden" name="package" value="{{ $d['package'] }}">
														

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																	<div class="col-md-12">
																		<div class="form-group">
																			<label><b>Application Type</b> <small style="color: red">*</small></label>
																			<div>
																				<label class="radio-inline">
																					<input type="radio" name="application" value="New" checked="">New
																				</label>
																				<label class="radio-inline">
																					<input type="radio" name="application" value="Upgrade">Upgrade
																				</label>
																				<label class="radio-inline">
																					<input type="radio" name="application" value="Relocation">Relocation (RM 150)
																				</label>
																			</div>
																		</div>
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																	<div class="col-md-12">
																		<div class="form-group">
																			<label><b>Full Name (as per MyKad/Passport)</b> <small style="color: red">*</small></label>
																			<input name="name" placeholder="Enter Full Name" class="form-control" type="text" required="" aria-required="true">																	
																		</div>
																	</div>
																	<div class="col-md-12">
																		<div class="form-group">
																			<label><b>Gender</b> <small style="color: red">*</small></label>
																			<select name="gender" id="gender" class="form-control">
																				<option value="male">Male</option>
																				<option value="female">Female</option>
																			</select>
																		</div>
																	</div>
																	<div class="col-md-6">
																		<div class="form-group">
																			<label><b>Nationality (Malaysian/Non-Malaysian)</b> <small style="color: red">*</small></label>
																			<select name="citizenship" id="citizenship" onchange="citizen()" class="form-control">
																				<option value="Malaysian">Malaysian</option>
																				<option value="Non">Non-Malaysian</option>
																			</select>
																					<select id="list" name="citizenlist" id="citizenlist"class="form-control" style="display:none">
																						<option value="" selected="selected">Select Country</option>
																						<option value="United States">United States</option>
																						<option value="United Kingdom">United Kingdom</option>
																						<option value="Afghanistan">Afghanistan</option>
																						<option value="Albania">Albania</option>
																						<option value="Algeria">Algeria</option>
																						<option value="American Samoa">American Samoa</option>
																						<option value="Andorra">Andorra</option>
																						<option value="Angola">Angola</option>
																						<option value="Anguilla">Anguilla</option>
																						<option value="Antarctica">Antarctica</option>
																						<option value="Antigua and Barbuda">Antigua and Barbuda</option>
																						<option value="Argentina">Argentina</option>
																						<option value="Armenia">Armenia</option>
																						<option value="Aruba">Aruba</option>
																						<option value="Australia">Australia</option>
																						<option value="Austria">Austria</option>
																						<option value="Azerbaijan">Azerbaijan</option>
																						<option value="Bahamas">Bahamas</option>
																						<option value="Bahrain">Bahrain</option>
																						<option value="Bangladesh">Bangladesh</option>
																						<option value="Barbados">Barbados</option>
																						<option value="Belarus">Belarus</option>
																						<option value="Belgium">Belgium</option>
																						<option value="Belize">Belize</option>
																						<option value="Benin">Benin</option>
																						<option value="Bermuda">Bermuda</option>
																						<option value="Bhutan">Bhutan</option>
																						<option value="Bolivia">Bolivia</option>
																						<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
																						<option value="Botswana">Botswana</option>
																						<option value="Bouvet Island">Bouvet Island</option>
																						<option value="Brazil">Brazil</option>
																						<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
																						<option value="Brunei Darussalam">Brunei Darussalam</option>
																						<option value="Bulgaria">Bulgaria</option>
																						<option value="Burkina Faso">Burkina Faso</option>
																						<option value="Burundi">Burundi</option>
																						<option value="Cambodia">Cambodia</option>
																						<option value="Cameroon">Cameroon</option>
																						<option value="Canada">Canada</option>
																						<option value="Cape Verde">Cape Verde</option>
																						<option value="Cayman Islands">Cayman Islands</option>
																						<option value="Central African Republic">Central African Republic</option>
																						<option value="Chad">Chad</option>
																						<option value="Chile">Chile</option>
																						<option value="China">China</option>
																						<option value="Christmas Island">Christmas Island</option>
																						<option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option>
																						<option value="Colombia">Colombia</option>
																						<option value="Comoros">Comoros</option>
																						<option value="Congo">Congo</option>
																						<option value="Congo, The Democratic Republic of The">Congo, The Democratic Republic of The</option>
																						<option value="Cook Islands">Cook Islands</option>
																						<option value="Costa Rica">Costa Rica</option>
																						<option value="Cote D'ivoire">Cote D'ivoire</option>
																						<option value="Croatia">Croatia</option>
																						<option value="Cuba">Cuba</option>
																						<option value="Cyprus">Cyprus</option>
																						<option value="Czech Republic">Czech Republic</option>
																						<option value="Denmark">Denmark</option>
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																						<option value="Dominica">Dominica</option>
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																						<option value="Falkland Islands (Malvinas)">Falkland Islands (Malvinas)</option>
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																						<option value="Fiji">Fiji</option>
																						<option value="Finland">Finland</option>
																						<option value="France">France</option>
																						<option value="French Guiana">French Guiana</option>
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																						<option value="French Southern Territories">French Southern Territories</option>
																						<option value="Gabon">Gabon</option>
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																						<option value="Georgia">Georgia</option>
																						<option value="Germany">Germany</option>
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																						<option value="Gibraltar">Gibraltar</option>
																						<option value="Greece">Greece</option>
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																						<option value="Holy See (Vatican City State)">Holy See (Vatican City State)</option>
																						<option value="Honduras">Honduras</option>
																						<option value="Hong Kong">Hong Kong</option>
																						<option value="Hungary">Hungary</option>
																						<option value="Iceland">Iceland</option>
																						<option value="India">India</option>
																						<option value="Indonesia">Indonesia</option>
																						<option value="Iran, Islamic Republic of">Iran, Islamic Republic of</option>
																						<option value="Iraq">Iraq</option>
																						<option value="Ireland">Ireland</option>
																						<option value="Israel">Israel</option>
																						<option value="Italy">Italy</option>
																						<option value="Jamaica">Jamaica</option>
																						<option value="Japan">Japan</option>
																						<option value="Jordan">Jordan</option>
																						<option value="Kazakhstan">Kazakhstan</option>
																						<option value="Kenya">Kenya</option>
																						<option value="Kiribati">Kiribati</option>
																						<option value="Korea, Democratic People's Republic of">Korea, Democratic People's Republic of</option>
																						<option value="Korea, Republic of">Korea, Republic of</option>
																						<option value="Kuwait">Kuwait</option>
																						<option value="Kyrgyzstan">Kyrgyzstan</option>
																						<option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option>
																						<option value="Latvia">Latvia</option>
																						<option value="Lebanon">Lebanon</option>
																						<option value="Lesotho">Lesotho</option>
																						<option value="Liberia">Liberia</option>
																						<option value="Libyan Arab Jamahiriya">Libyan Arab Jamahiriya</option>
																						<option value="Liechtenstein">Liechtenstein</option>
																						<option value="Lithuania">Lithuania</option>
																						<option value="Luxembourg">Luxembourg</option>
																						<option value="Macao">Macao</option>
																						<option value="Macedonia, The Former Yugoslav Republic of">Macedonia, The Former Yugoslav Republic of</option>
																						<option value="Madagascar">Madagascar</option>
																						<option value="Malawi">Malawi</option>
																						<option value="Malaysia">Malaysia</option>
																						<option value="Maldives">Maldives</option>
																						<option value="Mali">Mali</option>
																						<option value="Malta">Malta</option>
																						<option value="Marshall Islands">Marshall Islands</option>
																						<option value="Martinique">Martinique</option>
																						<option value="Mauritania">Mauritania</option>
																						<option value="Mauritius">Mauritius</option>
																						<option value="Mayotte">Mayotte</option>
																						<option value="Mexico">Mexico</option>
																						<option value="Micronesia, Federated States of">Micronesia, Federated States of</option>
																						<option value="Moldova, Republic of">Moldova, Republic of</option>
																						<option value="Monaco">Monaco</option>
																						<option value="Mongolia">Mongolia</option>
																						<option value="Montserrat">Montserrat</option>
																						<option value="Morocco">Morocco</option>
																						<option value="Mozambique">Mozambique</option>
																						<option value="Myanmar">Myanmar</option>
																						<option value="Namibia">Namibia</option>
																						<option value="Nauru">Nauru</option>
																						<option value="Nepal">Nepal</option>
																						<option value="Netherlands">Netherlands</option>
																						<option value="Netherlands Antilles">Netherlands Antilles</option>
																						<option value="New Caledonia">New Caledonia</option>
																						<option value="New Zealand">New Zealand</option>
																						<option value="Nicaragua">Nicaragua</option>
																						<option value="Niger">Niger</option>
																						<option value="Nigeria">Nigeria</option>
																						<option value="Niue">Niue</option>
																						<option value="Norfolk Island">Norfolk Island</option>
																						<option value="Northern Mariana Islands">Northern Mariana Islands</option>
																						<option value="Norway">Norway</option>
																						<option value="Oman">Oman</option>
																						<option value="Pakistan">Pakistan</option>
																						<option value="Palau">Palau</option>
																						<option value="Palestinian Territory, Occupied">Palestinian Territory, Occupied</option>
																						<option value="Panama">Panama</option>
																						<option value="Papua New Guinea">Papua New Guinea</option>
																						<option value="Paraguay">Paraguay</option>
																						<option value="Peru">Peru</option>
																						<option value="Philippines">Philippines</option>
																						<option value="Pitcairn">Pitcairn</option>
																						<option value="Poland">Poland</option>
																						<option value="Portugal">Portugal</option>
																						<option value="Puerto Rico">Puerto Rico</option>
																						<option value="Qatar">Qatar</option>
																						<option value="Reunion">Reunion</option>
																						<option value="Romania">Romania</option>
																						<option value="Russian Federation">Russian Federation</option>
																						<option value="Rwanda">Rwanda</option>
																						<option value="Saint Helena">Saint Helena</option>
																						<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
																						<option value="Saint Lucia">Saint Lucia</option>
																						<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
																						<option value="Saint Vincent and The Grenadines">Saint Vincent and The Grenadines</option>
																						<option value="Samoa">Samoa</option>
																						<option value="San Marino">San Marino</option>
																						<option value="Sao Tome and Principe">Sao Tome and Principe</option>
																						<option value="Saudi Arabia">Saudi Arabia</option>
																						<option value="Senegal">Senegal</option>
																						<option value="Serbia and Montenegro">Serbia and Montenegro</option>
																						<option value="Seychelles">Seychelles</option>
																						<option value="Sierra Leone">Sierra Leone</option>
																						<option value="Singapore">Singapore</option>
																						<option value="Slovakia">Slovakia</option>
																						<option value="Slovenia">Slovenia</option>
																						<option value="Solomon Islands">Solomon Islands</option>
																						<option value="Somalia">Somalia</option>
																						<option value="South Africa">South Africa</option>
																						<option value="South Georgia and The South Sandwich Islands">South Georgia and The South Sandwich Islands</option>
																						<option value="Spain">Spain</option>
																						<option value="Sri Lanka">Sri Lanka</option>
																						<option value="Sudan">Sudan</option>
																						<option value="Suriname">Suriname</option>
																						<option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>
																						<option value="Swaziland">Swaziland</option>
																						<option value="Sweden">Sweden</option>
																						<option value="Switzerland">Switzerland</option>
																						<option value="Syrian Arab Republic">Syrian Arab Republic</option>
																						<option value="Taiwan, Province of China">Taiwan, Province of China</option>
																						<option value="Tajikistan">Tajikistan</option>
																						<option value="Tanzania, United Republic of">Tanzania, United Republic of</option>
																						<option value="Thailand">Thailand</option>
																						<option value="Timor-leste">Timor-leste</option>
																						<option value="Togo">Togo</option>
																						<option value="Tokelau">Tokelau</option>
																						<option value="Tonga">Tonga</option>
																						<option value="Trinidad and Tobago">Trinidad and Tobago</option>
																						<option value="Tunisia">Tunisia</option>
																						<option value="Turkey">Turkey</option>
																						<option value="Turkmenistan">Turkmenistan</option>
																						<option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
																						<option value="Tuvalu">Tuvalu</option>
																						<option value="Uganda">Uganda</option>
																						<option value="Ukraine">Ukraine</option>
																						<option value="United Arab Emirates">United Arab Emirates</option>
																						<option value="United Kingdom">United Kingdom</option>
																						<option value="United States">United States</option>
																						<option value="United States Minor Outlying Islands">United States Minor Outlying Islands</option>
																						<option value="Uruguay">Uruguay</option>
																						<option value="Uzbekistan">Uzbekistan</option>
																						<option value="Vanuatu">Vanuatu</option>
																						<option value="Venezuela">Venezuela</option>
																						<option value="Viet Nam">Viet Nam</option>
																						<option value="Virgin Islands, British">Virgin Islands, British</option>
																						<option value="Virgin Islands, U.S.">Virgin Islands, U.S.</option>
																						<option value="Wallis and Futuna">Wallis and Futuna</option>
																						<option value="Western Sahara">Western Sahara</option>
																						<option value="Yemen">Yemen</option>
																						<option value="Zambia">Zambia</option>
																						<option value="Zimbabwe">Zimbabwe</option>
																					</select>
																					<small id="desc" style="color: red; display:none">A deposit of RM300 will be charge upfront prior installation.</small>
																		</div>
																	</div>

																	<div class="col-md-6">
																		<div class="form-group">
																			<label><b>MyKad / Passport</b> <small style="color: red">*</small></label>
																			<input id="nric1" name="nric_passport1" placeholder="Enter NRIC / Passport Number" class="form-control" type="text" required="" aria-required="true" style="display:block">
																			<textarea rows="6" id="nric2" name="nric_passport2" placeholder="Enter NRIC / Passport Number" class="form-control" type="text" required="" aria-required="true" style="display:none"></textarea>
																		</div>
																	</div>
																	<div class="col-md-6">
																		<div class="form-group">
																			<label><b>Contact Number (Primary) </b> <small style="color: red">*</small></label>
																			<input name="contact_primary" placeholder="Enter Primary Contact Number" class="form-control" type="tel" required="" aria-required="true">
																		</div>
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																	<div class="col-md-6">
																		<div class="form-group">
																			<label><b>Contact Number (Secondary)</b> </label>
																			<input name="contact_secondary" placeholder="Enter Secondary Contact Number" class="form-control" type="tel">
																		</div>
																	</div>
																	<div class="col-md-12">
																		<div class="form-group">
																			<label><b>Email</b> <small style="color: red">*</small></label>
																			<input name="email" placeholder="Enter Email" class="form-control" type="email" required="" aria-required="true">
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													</form>
													@endforeach
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	<script type="text/javascript" src="{{url('js/navigation.js')}}"></script>
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	<!-- Boostrap Wizard -->
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	<!--  Plugin for the Wizard -->
	<script src="{{url('js/gsdk.bootstrap.wizard.js')}}" type="text/javascript"></script>
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	<!-- DatePicker -->
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	<script src="{{url('js/signature_pad.ums.js')}}" type="text/javascript"></script>
	<script type="text/javascript">
		function citizen() {
			var val = $( "#citizenship" ).val();
			if (val =='Non') {
				document.getElementById("list").style.display="block";
				document.getElementById("nric2").style.display="block";
				document.getElementById("nric1").style.display="none";
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			}else{
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<style>
	select {
		height: 40px !important;
	}
	#nf-field-21-wrap .nf-field-label {
		padding-left: 5px;
	}
	.nf-field-element p {margin:0;}
	div#nf-field-22-container {
		margin: 0;
	} 
</style>