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allo/resources/views/sales/form/residential_application_inf...

residential_application_information.blade.php 37KB
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  1. <!DOCTYPE html>

  2. <html>

  3. <head>

  4. 	<style id="stndz-style"></style>

  5. 	<meta charset="UTF-8">

  6. 	<meta name="viewport" content="width=device-width, initial-scale=1">

  7. 	<style type="text/css">

  8. 	.step {

  9. 		height: 15px;

  10. 		width: 15px;

  11. 		margin: 0 2px;

  12. 		background-color: #bbbbbb;

  13. 		border: none;  

  14. 		border-radius: 50%;

  15. 		display: inline-block;

  16. 		opacity: 0.5;

  17. 	}

  18. 	</style>

  19. 	<link rel="profile" href="http://gmpg.org/xfn/11">

  20. 	<link rel="pingback" href="https://citybroadband.my/xmlrpc.php">

  21. 	<link href="https://fonts.googleapis.com/css?family=Open+Sans|Oswald:400,500|Signika:400,600" rel="stylesheet">

  22. 	<script type="text/javascript" async="" src="http://www.google-analytics.com/ga.js"></script><script type="text/javascript" src="https://ajax.googleapis.com/ajax/libs/jquery/1.10.2/jquery.min.js"></script>

  23. 	 

  24. 	<script src="https://maxcdn.bootstrapcdn.com/bootstrap/3.3.7/js/bootstrap.min.js" integrity="sha384-Tc5IQib027qvyjSMfHjOMaLkfuWVxZxUPnCJA7l2mCWNIpG9mGCD8wGNIcPD7Txa" crossorigin="anonymous"></script>

  25. 	<link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/bootstrap-datepicker/1.8.0/css/bootstrap-datepicker3.css">

  26. 	<title>Residential Application</title>

  27. 

  28. 	<link rel="dns-prefetch" href="//fonts.googleapis.com">

  29. 	<link rel="dns-prefetch" href="//s.w.org">

  30. 	<link rel="alternate" type="application/rss+xml" title="Cyberjaya Broadband » Feed" href="https://citybroadband.my/feed/">

  31. 	<link rel="alternate" type="application/rss+xml" title="Cyberjaya Broadband » Comments Feed" href="https://citybroadband.my/feed/">

  32. 		

  33. 	<link rel="icon" href="https://citybroadband.my/wp-content/uploads/2018/09/favicon-2.png" type="image/gif">

  34. 	<link rel="icon" href="https://citybroadband.my/wp-content/uploads/2018/09/favicon-3.png" type="image/png">

  35. 	<link rel="apple-touch-icon" href="https://citybroadband.my/wp-content/uploads/2018/09/favicon-4.png">

  36. 		

  37. 	<link rel="stylesheet" href="{{url('css/bootstrap.min.css')}}" type="text/css">

  38. 	<link rel="stylesheet" href="{{url('css/style.css')}}" type="text/css">

  39. 	

  40. 	<!-- Custom Signature files -->

  41. 	<!--<link rel="stylesheet" href="../include/plugins/signature_pad/docs/css/signature-pad.css">-->

  42. 	

  43. 	<!-- Font Awesome -->

  44. 	<link rel="stylesheet" href="https://use.fontawesome.com/releases/v5.2.0/css/all.css">

  45. 	

  46. 	<script type="text/javascript">

  47. 		var _gaq = _gaq || [];

  48. 		_gaq.push(['_setAccount', 'UA-39365077-1']);

  49. 		_gaq.push(['_trackPageview']);

  50. 		(function() {

  51. 		  var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;

  52. 		  ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';

  53. 		  var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);

  54. 		})();

  55. 	</script>

  56. 	<style type="text/css">

  57. 		input[type="text"], .tab-pane input[type="search"], input[type="email"], input[type="tel"], input[type="file"] {

  58. 		    height: 40px !important;

  59. 		    border: 1px solid #ccc !important;

  60. 		    border-radius: 4px;

  61. 		    margin-bottom: 0px;

  62. 		    background: #f5f5f5;

  63. 		}

  64. 	    footer {

  65. 		    padding: 40px 0 !important;

  66. 		}

  67. 	</style>

  68. </head>

  69. <body>

  70. 	<div id="page" class="site">

  71. 		<a class="skip-link screen-reader-text" href="#content">Skip to content</a>

  72. 

  73. 		<header id="masthead" class="site-header" role="banner">

  74. 			<div class="fixed-portal-login"><a href="http://userportal.citybroadband.my/login" target="_blank">User Portal Login</a></div></div>

  75. 

  76. 			<div class="nav-container">

  77. 				<nav id="site-navigation" class="main-navigation" role="navigation">

  78. 					<div class="container nav-bar">

  79. 						<div class="row">

  80. 							<div class="module left site-title-container">

  81. 								<a href="https://citybroadband.my">

  82. 									<img class="bigLogo" src="{{ url('assets/logo.png') }}" width="106" height="auto">

  83. 									<img class="smallLogo" src="{{ url('assets/logo.png') }}" width="106" height="auto">

  84. 								</a>

  85. 							</div>

  86. 							<div class="bigLogo module widget-handle search-widget-handle right hidden-xs">

  87. 								<div class="search">

  88. 									<form role="search" method="get" class="search-form" action="https://citybroadband.my/">

  89. 										<input type="search" class="search-field" placeholder="Search …" value="" name="s" title="Search for:" />

  90. 									</form>

  91. 								</div>

  92. 										 

  93. 							</div>

  94. 							<div class="module widget-handle mobile-toggle right visible-xs">

  95. 								<button type="button" class="navbar-toggle" data-toggle="collapse" data-target="#menu">

  96. 								   <span class="sr-only">Toggle navigation</span>

  97. 								   <span class="icon-bar"></span>

  98. 								   <span class="icon-bar"></span>

  99. 								   <span class="icon-bar"></span>

  100. 								</button>

  101. 							</div>

  102. 							<div style="clear: both;" class="module-group right menuholder">

  103. 								<div class="module left">

  104. 									<div class="collapse navbar-collapse navbar-ex1-collapse">

  105. 										<ul id="menu" class="menu">

  106. 											<li id="menu-item-16" class="menu-item menu-item-type-post_type menu-item-object-page menu-item-16"><a title="Residential" href="https://citybroadband.my/residential/">Residential</a></li>

  107. 											<li id="menu-item-15" class="menu-item menu-item-type-post_type menu-item-object-page menu-item-15"><a title="Business" href="https://citybroadband.my/business/">Business</a></li>

  108. 											<li id="menu-item-14" class="menu-item menu-item-type-post_type menu-item-object-page menu-item-14"><a title="Our Story" href="https://citybroadband.my/our-story/">Our Story</a></li>

  109. 											<li id="menu-item-13" class="menu-item menu-item-type-post_type menu-item-object-page menu-item-13"><a title="Support" href="https://citybroadband.my/support/">Support</a></li>

  110. 											<li id="menu-item-13" class="menu-item menu-item-type-post_type menu-item-object-page menu-item-12"><a title="Coverage Map" href="https://citybroadband.my/support/coverage-map/">Coverage Map</a></li>

  111. 											<li id="menu-item-12" class="menu-item menu-item-type-post_type menu-item-object-page menu-item-11"><a title="Contact Us" href="https://citybroadband.my/contact-us/">Contact Us</a></li>

  112. 										</ul>

  113. 									</div>

  114. 								</div>

  115. 								<div class="smallLogo module right">

  116. 									<form role="search" method="get" class="search-form" action="https://citybroadband.my/">

  117. 										<input type="search" class="search-field" placeholder="Search …" value="" name="s" title="Search for:" />

  118. 									</form>

  119. 								</div>

  120. 								<!--end of menu module-->

  121. 							</div>

  122. 							<!--end of module group-->

  123. 						</div>

  124. 					</div>

  125. 				</nav><!-- #site-navigation -->

  126. 			</div>

  127. 		</header><!-- #masthead -->

  128. 

  129. 

  130. 		<div id="content" class="main-container">

  131. 			<section class="content-area">

  132. 				<div id="main" role="main">

  133. 					<div class="bg-white splash-text" style="padding-bottom: 0">

  134. 						<div class="container">

  135. 							<h1 class="black text-center">Residential Application</h1>

  136. 							<p class="text-center">

  137. 								Please follow the steps below to complete your application. We will get back to you shortly.

  138. 							</p>

  139. 						</div>

  140. 					</div>

  141. 					<div class="container">

  142. 						<div class="row">

  143. 							<div class="col-md-8 col-md-offset-2">

  144. 								<section class="form-box">

  145. 									<div class="row">

  146. 										<div class="col-md-12">

  147. 											<!--      Wizard container        -->

  148. 											<div class="wizard-container">

  149. 												

  150. 												<div class="card wizard-card">

  151. 													<div class="wizard-navigation">

  152. 														<div>

  153. 															<ul class="nf-breadcrumbs nav nav-pills">

  154. 																<li style="width: 25%;"><a href="#address" class="nf-breadcrumb" data-toggle="tab" data-index="0" aria-expanded="true">Installation Address</a></li>

  155. 																<li class="active" style="width: 25%;"><a href="#information" class="nf-breadcrumb" data-toggle="tab" data-index="1">Application Information</a></li>

  156. 																<li style="width: 25%;"><a href="#service" class="nf-breadcrumb" data-toggle="tab" data-index="2">Service and Package Details</a></li>

  157. 																<li style="width: 25%;"><a href="#signaturess" class="nf-breadcrumb" data-toggle="tab" data-index="3">Preview</a></li>

  158. 															</ul>

  159. 														</div>

  160. 													</div>

  161. 

  162. 													@foreach($data as $d)

  163. 													<form action="{{url('/residential/'.$d['package'].'/application-form/service_package')}}" method="post" enctype="multipart/form-data" name="registerForm" novalidate="novalidate">

  164. 

  165. 														<input type="hidden" name="_token" value="<?php echo csrf_token(); ?>">

  166. 														<input type="hidden" name="nama_form" value="second">

  167. 

  168. 														<!-- Input from previous form: step 1 -->

  169. 														

  170. 														<input type="hidden" name="coverage" value="{{ $d['coverage'] }}">

  171. 														<input type="hidden" name="unit" value="{{ $d['unit'] }}">

  172. 														<input type="hidden" name="street" value="{{ $d['street'] }}">

  173. 														<input type="hidden" name="package" value="{{ $d['package'] }}">

  174. 														

  175. 

  176. 														<div class="tracking-process" ></div>

  177. 

  178. 														<div>

  179. 															<div class="inner-pane">

  180. 																<div class="row">

  181. 																	<div class="col-md-12">

  182. 																		<div class="form-group">

  183. 																			<label><b>Application Type</b> <small style="color: red">*</small></label>

  184. 																			<div>

  185. 																				<label class="radio-inline">

  186. 																					<input type="radio" name="application" value="New" checked="">New

  187. 																				</label>

  188. 																				<label class="radio-inline">

  189. 																					<input type="radio" name="application" value="Upgrade">Upgrade

  190. 																				</label>

  191. 																				<label class="radio-inline">

  192. 																					<input type="radio" name="application" value="Relocation">Relocation (RM 150)

  193. 																				</label>

  194. 																			</div>

  195. 																		</div>

  196. 																	</div>

  197. 																	<div class="col-md-12">

  198. 																		<div class="form-group">

  199. 																			<label><b>Full Name (as per MyKad/Passport)</b> <small style="color: red">*</small></label>

  200. 																			<input name="name" placeholder="Enter Full Name" class="form-control" type="text" required="" aria-required="true">																	

  201. 																		</div>

  202. 																	</div>

  203. 																	<div class="col-md-12">

  204. 																		<div class="form-group">

  205. 																			<label><b>Gender</b> <small style="color: red">*</small></label>

  206. 																			<select name="gender" id="gender" class="form-control">

  207. 																				<option value="male">Male</option>

  208. 																				<option value="female">Female</option>

  209. 																			</select>

  210. 																		</div>

  211. 																	</div>

  212. 																	<div class="col-md-6">

  213. 																		<div class="form-group">

  214. 																			<label><b>Nationality (Malaysian/Non-Malaysian)</b> <small style="color: red">*</small></label>

  215. 																			<select name="citizenship" id="citizenship" onchange="citizen()" class="form-control">

  216. 																				<option value="Malaysian">Malaysian</option>

  217. 																				<option value="Non">Non-Malaysian</option>

  218. 																			</select>

  219. 																					<select id="list" name="citizenlist" id="citizenlist"class="form-control" style="display:none">

  220. 																						<option value="" selected="selected">Select Country</option>

  221. 																						<option value="United States">United States</option>

  222. 																						<option value="United Kingdom">United Kingdom</option>

  223. 																						<option value="Afghanistan">Afghanistan</option>

  224. 																						<option value="Albania">Albania</option>

  225. 																						<option value="Algeria">Algeria</option>

  226. 																						<option value="American Samoa">American Samoa</option>

  227. 																						<option value="Andorra">Andorra</option>

  228. 																						<option value="Angola">Angola</option>

  229. 																						<option value="Anguilla">Anguilla</option>

  230. 																						<option value="Antarctica">Antarctica</option>

  231. 																						<option value="Antigua and Barbuda">Antigua and Barbuda</option>

  232. 																						<option value="Argentina">Argentina</option>

  233. 																						<option value="Armenia">Armenia</option>

  234. 																						<option value="Aruba">Aruba</option>

  235. 																						<option value="Australia">Australia</option>

  236. 																						<option value="Austria">Austria</option>

  237. 																						<option value="Azerbaijan">Azerbaijan</option>

  238. 																						<option value="Bahamas">Bahamas</option>

  239. 																						<option value="Bahrain">Bahrain</option>

  240. 																						<option value="Bangladesh">Bangladesh</option>

  241. 																						<option value="Barbados">Barbados</option>

  242. 																						<option value="Belarus">Belarus</option>

  243. 																						<option value="Belgium">Belgium</option>

  244. 																						<option value="Belize">Belize</option>

  245. 																						<option value="Benin">Benin</option>

  246. 																						<option value="Bermuda">Bermuda</option>

  247. 																						<option value="Bhutan">Bhutan</option>

  248. 																						<option value="Bolivia">Bolivia</option>

  249. 																						<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>

  250. 																						<option value="Botswana">Botswana</option>

  251. 																						<option value="Bouvet Island">Bouvet Island</option>

  252. 																						<option value="Brazil">Brazil</option>

  253. 																						<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>

  254. 																						<option value="Brunei Darussalam">Brunei Darussalam</option>

  255. 																						<option value="Bulgaria">Bulgaria</option>

  256. 																						<option value="Burkina Faso">Burkina Faso</option>

  257. 																						<option value="Burundi">Burundi</option>

  258. 																						<option value="Cambodia">Cambodia</option>

  259. 																						<option value="Cameroon">Cameroon</option>

  260. 																						<option value="Canada">Canada</option>

  261. 																						<option value="Cape Verde">Cape Verde</option>

  262. 																						<option value="Cayman Islands">Cayman Islands</option>

  263. 																						<option value="Central African Republic">Central African Republic</option>

  264. 																						<option value="Chad">Chad</option>

  265. 																						<option value="Chile">Chile</option>

  266. 																						<option value="China">China</option>

  267. 																						<option value="Christmas Island">Christmas Island</option>

  268. 																						<option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option>

  269. 																						<option value="Colombia">Colombia</option>

  270. 																						<option value="Comoros">Comoros</option>

  271. 																						<option value="Congo">Congo</option>

  272. 																						<option value="Congo, The Democratic Republic of The">Congo, The Democratic Republic of The</option>

  273. 																						<option value="Cook Islands">Cook Islands</option>

  274. 																						<option value="Costa Rica">Costa Rica</option>

  275. 																						<option value="Cote D'ivoire">Cote D'ivoire</option>

  276. 																						<option value="Croatia">Croatia</option>

  277. 																						<option value="Cuba">Cuba</option>

  278. 																						<option value="Cyprus">Cyprus</option>

  279. 																						<option value="Czech Republic">Czech Republic</option>

  280. 																						<option value="Denmark">Denmark</option>

  281. 																						<option value="Djibouti">Djibouti</option>

  282. 																						<option value="Dominica">Dominica</option>

  283. 																						<option value="Dominican Republic">Dominican Republic</option>

  284. 																						<option value="Ecuador">Ecuador</option>

  285. 																						<option value="Egypt">Egypt</option>

  286. 																						<option value="El Salvador">El Salvador</option>

  287. 																						<option value="Equatorial Guinea">Equatorial Guinea</option>

  288. 																						<option value="Eritrea">Eritrea</option>

  289. 																						<option value="Estonia">Estonia</option>

  290. 																						<option value="Ethiopia">Ethiopia</option>

  291. 																						<option value="Falkland Islands (Malvinas)">Falkland Islands (Malvinas)</option>

  292. 																						<option value="Faroe Islands">Faroe Islands</option>

  293. 																						<option value="Fiji">Fiji</option>

  294. 																						<option value="Finland">Finland</option>

  295. 																						<option value="France">France</option>

  296. 																						<option value="French Guiana">French Guiana</option>

  297. 																						<option value="French Polynesia">French Polynesia</option>

  298. 																						<option value="French Southern Territories">French Southern Territories</option>

  299. 																						<option value="Gabon">Gabon</option>

  300. 																						<option value="Gambia">Gambia</option>

  301. 																						<option value="Georgia">Georgia</option>

  302. 																						<option value="Germany">Germany</option>

  303. 																						<option value="Ghana">Ghana</option>

  304. 																						<option value="Gibraltar">Gibraltar</option>

  305. 																						<option value="Greece">Greece</option>

  306. 																						<option value="Greenland">Greenland</option>

  307. 																						<option value="Grenada">Grenada</option>

  308. 																						<option value="Guadeloupe">Guadeloupe</option>

  309. 																						<option value="Guam">Guam</option>

  310. 																						<option value="Guatemala">Guatemala</option>

  311. 																						<option value="Guinea">Guinea</option>

  312. 																						<option value="Guinea-bissau">Guinea-bissau</option>

  313. 																						<option value="Guyana">Guyana</option>

  314. 																						<option value="Haiti">Haiti</option>

  315. 																						<option value="Heard Island and Mcdonald Islands">Heard Island and Mcdonald Islands</option>

  316. 																						<option value="Holy See (Vatican City State)">Holy See (Vatican City State)</option>

  317. 																						<option value="Honduras">Honduras</option>

  318. 																						<option value="Hong Kong">Hong Kong</option>

  319. 																						<option value="Hungary">Hungary</option>

  320. 																						<option value="Iceland">Iceland</option>

  321. 																						<option value="India">India</option>

  322. 																						<option value="Indonesia">Indonesia</option>

  323. 																						<option value="Iran, Islamic Republic of">Iran, Islamic Republic of</option>

  324. 																						<option value="Iraq">Iraq</option>

  325. 																						<option value="Ireland">Ireland</option>

  326. 																						<option value="Israel">Israel</option>

  327. 																						<option value="Italy">Italy</option>

  328. 																						<option value="Jamaica">Jamaica</option>

  329. 																						<option value="Japan">Japan</option>

  330. 																						<option value="Jordan">Jordan</option>

  331. 																						<option value="Kazakhstan">Kazakhstan</option>

  332. 																						<option value="Kenya">Kenya</option>

  333. 																						<option value="Kiribati">Kiribati</option>

  334. 																						<option value="Korea, Democratic People's Republic of">Korea, Democratic People's Republic of</option>

  335. 																						<option value="Korea, Republic of">Korea, Republic of</option>

  336. 																						<option value="Kuwait">Kuwait</option>

  337. 																						<option value="Kyrgyzstan">Kyrgyzstan</option>

  338. 																						<option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option>

  339. 																						<option value="Latvia">Latvia</option>

  340. 																						<option value="Lebanon">Lebanon</option>

  341. 																						<option value="Lesotho">Lesotho</option>

  342. 																						<option value="Liberia">Liberia</option>

  343. 																						<option value="Libyan Arab Jamahiriya">Libyan Arab Jamahiriya</option>

  344. 																						<option value="Liechtenstein">Liechtenstein</option>

  345. 																						<option value="Lithuania">Lithuania</option>

  346. 																						<option value="Luxembourg">Luxembourg</option>

  347. 																						<option value="Macao">Macao</option>

  348. 																						<option value="Macedonia, The Former Yugoslav Republic of">Macedonia, The Former Yugoslav Republic of</option>

  349. 																						<option value="Madagascar">Madagascar</option>

  350. 																						<option value="Malawi">Malawi</option>

  351. 																						<option value="Malaysia">Malaysia</option>

  352. 																						<option value="Maldives">Maldives</option>

  353. 																						<option value="Mali">Mali</option>

  354. 																						<option value="Malta">Malta</option>

  355. 																						<option value="Marshall Islands">Marshall Islands</option>

  356. 																						<option value="Martinique">Martinique</option>

  357. 																						<option value="Mauritania">Mauritania</option>

  358. 																						<option value="Mauritius">Mauritius</option>

  359. 																						<option value="Mayotte">Mayotte</option>

  360. 																						<option value="Mexico">Mexico</option>

  361. 																						<option value="Micronesia, Federated States of">Micronesia, Federated States of</option>

  362. 																						<option value="Moldova, Republic of">Moldova, Republic of</option>

  363. 																						<option value="Monaco">Monaco</option>

  364. 																						<option value="Mongolia">Mongolia</option>

  365. 																						<option value="Montserrat">Montserrat</option>

  366. 																						<option value="Morocco">Morocco</option>

  367. 																						<option value="Mozambique">Mozambique</option>

  368. 																						<option value="Myanmar">Myanmar</option>

  369. 																						<option value="Namibia">Namibia</option>

  370. 																						<option value="Nauru">Nauru</option>

  371. 																						<option value="Nepal">Nepal</option>

  372. 																						<option value="Netherlands">Netherlands</option>

  373. 																						<option value="Netherlands Antilles">Netherlands Antilles</option>

  374. 																						<option value="New Caledonia">New Caledonia</option>

  375. 																						<option value="New Zealand">New Zealand</option>

  376. 																						<option value="Nicaragua">Nicaragua</option>

  377. 																						<option value="Niger">Niger</option>

  378. 																						<option value="Nigeria">Nigeria</option>

  379. 																						<option value="Niue">Niue</option>

  380. 																						<option value="Norfolk Island">Norfolk Island</option>

  381. 																						<option value="Northern Mariana Islands">Northern Mariana Islands</option>

  382. 																						<option value="Norway">Norway</option>

  383. 																						<option value="Oman">Oman</option>

  384. 																						<option value="Pakistan">Pakistan</option>

  385. 																						<option value="Palau">Palau</option>

  386. 																						<option value="Palestinian Territory, Occupied">Palestinian Territory, Occupied</option>

  387. 																						<option value="Panama">Panama</option>

  388. 																						<option value="Papua New Guinea">Papua New Guinea</option>

  389. 																						<option value="Paraguay">Paraguay</option>

  390. 																						<option value="Peru">Peru</option>

  391. 																						<option value="Philippines">Philippines</option>

  392. 																						<option value="Pitcairn">Pitcairn</option>

  393. 																						<option value="Poland">Poland</option>

  394. 																						<option value="Portugal">Portugal</option>

  395. 																						<option value="Puerto Rico">Puerto Rico</option>

  396. 																						<option value="Qatar">Qatar</option>

  397. 																						<option value="Reunion">Reunion</option>

  398. 																						<option value="Romania">Romania</option>

  399. 																						<option value="Russian Federation">Russian Federation</option>

  400. 																						<option value="Rwanda">Rwanda</option>

  401. 																						<option value="Saint Helena">Saint Helena</option>

  402. 																						<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>

  403. 																						<option value="Saint Lucia">Saint Lucia</option>

  404. 																						<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>

  405. 																						<option value="Saint Vincent and The Grenadines">Saint Vincent and The Grenadines</option>

  406. 																						<option value="Samoa">Samoa</option>

  407. 																						<option value="San Marino">San Marino</option>

  408. 																						<option value="Sao Tome and Principe">Sao Tome and Principe</option>

  409. 																						<option value="Saudi Arabia">Saudi Arabia</option>

  410. 																						<option value="Senegal">Senegal</option>

  411. 																						<option value="Serbia and Montenegro">Serbia and Montenegro</option>

  412. 																						<option value="Seychelles">Seychelles</option>

  413. 																						<option value="Sierra Leone">Sierra Leone</option>

  414. 																						<option value="Singapore">Singapore</option>

  415. 																						<option value="Slovakia">Slovakia</option>

  416. 																						<option value="Slovenia">Slovenia</option>

  417. 																						<option value="Solomon Islands">Solomon Islands</option>

  418. 																						<option value="Somalia">Somalia</option>

  419. 																						<option value="South Africa">South Africa</option>

  420. 																						<option value="South Georgia and The South Sandwich Islands">South Georgia and The South Sandwich Islands</option>

  421. 																						<option value="Spain">Spain</option>

  422. 																						<option value="Sri Lanka">Sri Lanka</option>

  423. 																						<option value="Sudan">Sudan</option>

  424. 																						<option value="Suriname">Suriname</option>

  425. 																						<option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>

  426. 																						<option value="Swaziland">Swaziland</option>

  427. 																						<option value="Sweden">Sweden</option>

  428. 																						<option value="Switzerland">Switzerland</option>

  429. 																						<option value="Syrian Arab Republic">Syrian Arab Republic</option>

  430. 																						<option value="Taiwan, Province of China">Taiwan, Province of China</option>

  431. 																						<option value="Tajikistan">Tajikistan</option>

  432. 																						<option value="Tanzania, United Republic of">Tanzania, United Republic of</option>

  433. 																						<option value="Thailand">Thailand</option>

  434. 																						<option value="Timor-leste">Timor-leste</option>

  435. 																						<option value="Togo">Togo</option>

  436. 																						<option value="Tokelau">Tokelau</option>

  437. 																						<option value="Tonga">Tonga</option>

  438. 																						<option value="Trinidad and Tobago">Trinidad and Tobago</option>

  439. 																						<option value="Tunisia">Tunisia</option>

  440. 																						<option value="Turkey">Turkey</option>

  441. 																						<option value="Turkmenistan">Turkmenistan</option>

  442. 																						<option value="Turks and Caicos Islands">Turks and Caicos Islands</option>

  443. 																						<option value="Tuvalu">Tuvalu</option>

  444. 																						<option value="Uganda">Uganda</option>

  445. 																						<option value="Ukraine">Ukraine</option>

  446. 																						<option value="United Arab Emirates">United Arab Emirates</option>

  447. 																						<option value="United Kingdom">United Kingdom</option>

  448. 																						<option value="United States">United States</option>

  449. 																						<option value="United States Minor Outlying Islands">United States Minor Outlying Islands</option>

  450. 																						<option value="Uruguay">Uruguay</option>

  451. 																						<option value="Uzbekistan">Uzbekistan</option>

  452. 																						<option value="Vanuatu">Vanuatu</option>

  453. 																						<option value="Venezuela">Venezuela</option>

  454. 																						<option value="Viet Nam">Viet Nam</option>

  455. 																						<option value="Virgin Islands, British">Virgin Islands, British</option>

  456. 																						<option value="Virgin Islands, U.S.">Virgin Islands, U.S.</option>

  457. 																						<option value="Wallis and Futuna">Wallis and Futuna</option>

  458. 																						<option value="Western Sahara">Western Sahara</option>

  459. 																						<option value="Yemen">Yemen</option>

  460. 																						<option value="Zambia">Zambia</option>

  461. 																						<option value="Zimbabwe">Zimbabwe</option>

  462. 																					</select>

  463. 																					<small id="desc" style="color: red; display:none">A deposit of RM300 will be charge upfront prior installation.</small>	

  464. 																		</div>

  465. 																	</div>

  466. 																	<div class="col-md-6">

  467. 																		<div class="form-group">

  468. 																			<label><b>MyKad / Passport</b> <small style="color: red">*</small></label>

  469. 																			<input id="nric1" name="nric_passport1" placeholder="Enter NRIC / Passport Number" class="form-control" type="text" required="" aria-required="true" style="display:block">

  470. 																			<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>

  471. 																		</div>

  472. 																	</div>

  473. 																	<div class="col-md-6">

  474. 																		<div class="form-group">

  475. 																			<label><b>Contact Number (Primary) </b> <small style="color: red">*</small></label>

  476. 																			<input name="contact_primary" placeholder="Enter Primary Contact Number" class="form-control" type="tel" required="" aria-required="true">

  477. 																		</div>

  478. 																	</div>

  479. 																	<div class="col-md-6">

  480. 																		<div class="form-group">

  481. 																			<label><b>Contact Number (Secondary)</b> </label>

  482. 																			<input name="contact_secondary" placeholder="Enter Secondary Contact Number" class="form-control" type="tel">

  483. 																		</div>

  484. 																	</div>

  485. 																	<div class="col-md-12">

  486. 																		<div class="form-group">

  487. 																			<label><b>Email</b> <small style="color: red">*</small></label>

  488. 																			<input name="email" placeholder="Enter Email" class="form-control" type="email" required="" aria-required="true">

  489. 																		</div>

  490. 																	</div>

  491. 																</div>

  492. 															</div>

  493. 														</div>

  494. 

  495. 														<!-- Wizard Footer -->

  496. 														<div class="wizard-footer height-wizard">

  497. 															<div class="wizard-footer-inner">

  498. 																<div class="pull-right">

  499. 																	<!-- <a href="{{url('Residential/form2')}}"> -->

  500. 																	<button type="submit" class="btn btn-next" name="next" value="Next" style="background-color: orangered; display: inline-block;">Next</button>

  501. 																	<input type="button" id="save-data" class="btn btn-finish" data-loading-text="Please Wait..." name="finish" value="Submit" style="display: none;">

  502. 																	<!-- </a> -->

  503. 																</div>

  504. 																

  505. 																<div class="pull-left">

  506. 																	<a href="javascript:history.back()">

  507. 																		<input type="button" class="btn btn-previous" name="previous" value="Previous" style="background-color: grey;">

  508. 																	</a>

  509. 																</div>

  510. 																<div class="clearfix"></div>

  511. 															</div>

  512. 														</div>	

  513. 													</form>

  514. 													@endforeach

  515. 												</div>

  516. 											</div>

  517. 											<!-- End Wizard Form -->

  518. 										</div>	

  519. 									</div>

  520. 								</section>

  521. 							</div>

  522. 						</div>

  523. 					</div>

  524. 					<div class="nonstick-footer padding bg-blue" align="center">

  525. 						<span class="medium-title text-centeryellow" style="color: yellow;">Got A Question?</span>

  526. 						<div align="center">

  527. 							<a class="nomargin btn btn-default" href="#" style="width: 230px;">

  528. 								Read FAQ

  529. 							</a>

  530. 							<a style="width:230px" href="#" class="nomargin btn btn-default">

  531. 								Write to us

  532. 							</a>

  533. 						</div>

  534. 					</div>

  535. 				</div>

  536. 			</section>

  537. 		</div>

  538. 		<div class="footer-callout"></div>

  539. 	<footer id="colophon" class="site-footer footer" role="contentinfo">

  540. 		<div class="container footer-inner">

  541. 			<div class="row">

  542. 				<div class="footer-widget-area">

  543. 					<div class="col-md-6 col-md-3 footer-widget" role="complementary">

  544. 						<div class="widget widget_nav_menu" id="nav_menu-3">

  545. 							<h2 class="widget-title">Overview</h2>

  546. 							<div class="menu-main-container">

  547. 								<ul id="menu-main" class="menu">

  548. 									<li class="menu-item menu-item-type-post_type menu-item-object-page menu-item-16">

  549. 										<a href="https://citybroadband.my/residential/">Residential</a>

  550. 									</li>

  551. 									<li class="menu-item menu-item-type-post_type menu-item-object-page menu-item-15">

  552. 										<a href="https://citybroadband.my/business/">Business</a>

  553. 									</li>

  554. 									<li class="menu-item menu-item-type-post_type menu-item-object-page menu-item-14">

  555. 										<a href="https://citybroadband.my/our-story/">Our Story</a>

  556. 									</li>

  557. 									<li class="menu-item menu-item-type-post_type menu-item-object-page menu-item-13">

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  559. 									</li>

  560. 									<li class="menu-item menu-item-type-post_type menu-item-object-page menu-item-13">

  561. 										<a href="https://citybroadband.my/support/coverage-map/">Coverage Map</a>

  562. 									</li>

  563. 									<li class="menu-item menu-item-type-post_type menu-item-object-page menu-item-12">

  564. 										<a href="https://citybroadband.my/contact-us/">Contact Us</a>

  565. 									</li>

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  567. 							</div>

  568. 						</div>

  569. 					</div>

  570. 					<div class="col-md-3 col-sm-6 footer-widget" role="complementary">

  571. 						<div id="nav_menu-2" class="widget widget_nav_menu">

  572. 							<h2 class="widget-title">Legal</h2>

  573. 							<div class="menu-footer-2-container">

  574. 								<ul id="menu-footer-2" class="menu">

  575. 									<li id="menu-item-22" class="menu-item menu-item-type-post_type menu-item-object-page menu-item-22">

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  578. 									<li id="menu-item-373" class="menu-item menu-item-type-post_type menu-item-object-page menu-item-373">

  579. 										<a href="https://citybroadband.my/privacy-policy/">Privacy Policy</a>

  580. 									</li>

  581. 									<li id="menu-item-373" class="menu-item menu-item-type-post_type menu-item-object-page menu-item-373">

  582. 										<a href="https://citybroadband.my/refund-policy/">Refund Policy</a>

  583. 									</li>

  584. 								</ul>

  585. 							</div>

  586. 						</div>

  587. 					</div>

  588. 					<div class="col-md-3 col-sm-6 footer-widget" role="complementary">

  589. 						<div id="text-2" class="widget widget_text">

  590. 							<h2 class="widget-title">Hotline</h2>			

  591. 							<div class="textwidget"><span class="number-big yellow">1300-38-8000</span></div>

  592. 						</div>	

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  594. 					<div class="col-md-3 col-sm-6 footer-widget" role="complementary">

  595. 						<div id="text-4" class="widget widget_text">

  596. 							<h2 class="widget-title">We Accept</h2>	

  597. 							<div class="textwidget"><img src="https://citybroadband.my/wp-content/themes/cb1g/assets/images/weaccept.png"></div>

  598. 						</div>

  599. 					</div>

  600. 				</div>

  601. 			</div>

  602. 		</div>

  603. 		<div class="container">

  604. 			<div class="lowerfooter">

  605. 				<img width="50px" src="{{url('assets/logo/footerlogo.png')}}" align="left">

  606. 				<span class="lower-disclaimer">Copyright © 2019 Allo Technology Sdn Bhd. All rights reserved.</span>

  607. 			</div>

  608. 			<a class="btn btn-sm fade-half back-to-top inner-link" href="#top"><i class="fa fa-angle-up"></i></a>

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  611. 	<script type="text/javascript" src="{{url('js/navigation.js')}}"></script>

  612. 	<script type="text/javascript" src="{{url('js/skip-link-focus.js')}}"></script>

  613. 	

  614. 	<!-- Boostrap Wizard -->

  615. 	<script src="{{url('js/jquery.bootstrap.wizard.js')}}" type="text/javascript"></script>

  616. 	<!--  Plugin for the Wizard -->

  617. 	<script src="{{url('js/gsdk.bootstrap.wizard.js')}}" type="text/javascript"></script>

  618. 	<script src="{{url('js/jquery.validate.min.js')}}" type="text/javascript"></script>

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  666. 	select {

  667. 		height: 40px !important;

  668. 	}

  669. 	#nf-field-21-wrap .nf-field-label {

  670. 		padding-left: 5px;

  671. 	}

  672. 	.nf-field-element p {margin:0;}

  673. 	div#nf-field-22-container {

  674. 		margin: 0;

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