muadzmi02
/
allo
форк від SwissLink/allo


			
				
					
						
						
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	<title>Residential Application</title>

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<body>
	<div id="page" class="site">
		<a class="skip-link screen-reader-text" href="#"></a>
		<header id="masthead" class="site-header" role="banner">
			<div class="fixed-portal-login">
				<a href="#" target="_blank">User Portal Login</a>
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		<nav id="site-navigation" class="main-navigation" role="navigation">
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					<div class="module left site-title-container">
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							<img class="bigLogo" src="{{url('assets/logo/cbb_new_logo2.png')}}" width="106" height="auto">
							<img class="smallLogo" src="{{url('assets/logo/cbb_new_logo2.png')}}" width="106" height="auto">
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					<div class="bigLogo module widget-handle search-widget-handle right hidden-xs">
						<div class="search">
							<form role="search" method="get" class="search-form" action="#">
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								<li id="menu-item-16" class="menu-item menu-item-type-post_type menu-item-object-page menu-item-16">
									<a title="Residential" href="#">Residential</a>
								</li>
								<li id="menu-item-15" class="menu-item menu-item-type-post_type menu-item-object-page menu-item-15">
									<a title="Business" href="#">Business</a>
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	<div id="content" class="main-container">
		<section class="content-area">
			<div id="main" role="main">
				<div class="bg-white splash-text" style="padding-bottom: 0">
					<div class="container">
						<h1 class="black text-center">Business Application</h1>
						<p class="text-center">
							"Please follow the steps below to complete your application. We will get back to you shortly."
						</p>
					</div>
				</div>
				<div class="container">
					<div class="row">
						<div class="col-md-13">
							<section class="form-box">
								<div class="row">
									<div class="container">
										@foreach($data as $a)
										<form action method="post" ectype="multipart/form-data" name="registerForm" novalidate="novalidate">
											<div class="tracking-process" >
											</div>
											<div class="moving-tab" style="width: 180px; transition: transform 0s ease 0s;">
												Preview
											</div>
											<div class="tab-content">
												<div class="tab-pane active" id="signaturess">
													<div class="inner-pane">
														<!-- Preview -->
														<div class="row">
															<div class="col-md-12">
																<div id="preview">
																	<label><b>Subscription Details</b></label>
																	<table class="table table-sm table-bordered">
																		<tbody>
																			<tr><th>Type Application</th>
																				<td>{{$a['application']}}</td>
																			</tr>
																			<tr><th>Residential Package</th>
																				<td>10Mbps</td>
																			</tr>
																			<tr><th>Contract Term</th>
																				<td>{{$a['subscription']}} Months</td>
																			</tr>
																			<tr><th>Prefered Appointment Date</th>
																				<td>{{$a['thedate']}}</td>
																			</tr>
																		</tbody>
																	</table>
																	<hr><label><b>Add-On(s)</b></label>
																	<table class="table table-sm table-bordered">
																		<tbody>
																			<tr><th>Subscribe for Voice</th>
																				<td>{{$a['voice']}}</td>
																			</tr>
																		</tbody>
																	</table>
																	<hr><label><b>Company Details</b></label>
																	<table class="table table-sm table-bordered">
																		<tbody>
																			<tr><th>Company Name</th>
																				<td>{{$a['company_name']}}</td>
																			</tr>
																			<tr><th>Business Reg.No</th>
																				<td>{{$a['company_register']}}</td>
																			</tr>
																			<tr><th>Company Contact No.</th>
																				<td>{{$a['company_number']}}</td>
																			</tr>
																			<tr><th>Company Fax No.</th>
																				<td>{{$a['company_fax']}}</td>
																			</tr>
																		</tbody>
																	</table>
																	<hr><label><b>Technical Contact Person</b></label>
																	<table class="table table-sm table-bordered">
																		<tbody>
																			<tr><th>Full Name</th>
																				<td>{{$a['full_name']}}</td>
																			</tr>
																			<tr><th>MyKad/Passport</th>
																				<td>{{$a['nric_passport']}}</td>
																			</tr>
																			<tr><th>Designation</th>
																				<td>{{$a['designation']}}</td>
																			</tr>
																			<tr><th>Primary Phone Number</th>
																				<td>{{$a['contact_primary']}}</td>
																			</tr>
																			<tr><th>Secondary Phone Number</th>
																				<td>{{$a['contact_secondary']}}</td>
																			</tr>
																			<tr><th>Email Address</th>
																				<td>{{$a['email']}}</td>
																			</tr>
																		</tbody>
																	</table>
																	<hr><label><b>Service Installation Address</b></label>
																	<table class="table table-sm table-bordered">
																		<tbody>
																			<tr><th>Address</th>
																				<td>{{$a['caddress']}}</td>
																			</tr>
																			<tr><th>Postcode</th>
																				<td>{{$a['postcode']}}</td>
																			</tr>
																			<tr><th>City</th>
																				<td>{{$a['ccity']}}</td>
																			</tr>
																			<tr><th>State</th>
																				<td>{{$a['cstate']}}</td>
																			</tr>
																		</tbody>
																	</table>
																	<hr><label><b>Montly Recurring Fee</b></label>
																	<table class="table table-sm table-bordered">
																		<tbody>
																			<tr><th>Description</th><th>Price excl. ST</th><th>With ST (6%)</th>
																			</tr>
																			<tr><th>Broadband Fee</th>
																				<td>149</td>
																				<td>157.94</td>
																			</tr>
																			<tr><th colspan="2">Deposit</th>
																				<td>149</td>
																			</tr>
																			<tr><th colspan="2">OTC</th>
																				<td>0.0</td>
																			</tr>
																			<tr><th colspan="2">Total Charges</th>
																				<td>306.94</td>
																			</tr>
																		</tbody>
																	</table>
																</div>
															</div>
														</div>
													</div>

													<!-- Document -->
													<h3>Declaration and Signature</h3>
													<div class="inner-pane">
														<div class="row">
															<div class="col-md-12" id="document">
																<label><b>Document &amp; Declaration </b><small style="color: red">*</small></label>
																<div class="form-group">
																	<div class="checkbox">
																		<label>
																			<input type="checkbox" name="photocopy" id="photocopy" value="24" required="" aria-required="true"> <p>Photocopy of MyKad (front and back) or passport for Non-Malaysian (minimum 12 months validity)</p>
																		</label>
																	</div>
																	<div class="checkbox">
																		<label>
																			<input type="checkbox" name="formss" id="formss" value="24" required="" aria-required="true"> <p>Photocopy of Form 9, 24, 44 &amp; 49 </p>
																		</label>
																	</div>
																	<div class="checkbox">
																		<label>
																			<input type="checkbox" name="consent" id="consent" value="24" required="" aria-required="true"> <p>I hereby consent to the collection, use,
																				disclosure of my personal information in accordance with the <b> Privacy Policy </b> available one www.citybroadband.my.</p>
																			</label>
																		</div>
																		<div class="checkbox">
																			<label>
																				<input type="checkbox" name="declare" id="declare" value="24" required="" aria-required="true"> <p>I hereby declare that the above information, documents, and
																					any appendices attached are true and valid. I have read and understood the contents of this form and agreed to be bound by <b> Terms &amp; Condition </b>
																					as stated on the next page of this form which accompany the subscription of product(s) and/ or service(s). Allo Haruman Technology Sdn Bhd reserve the rights
																					to refuse any application  at any given time should any of the information is incorrect.
																				</p>
																			</label>
																		</div>
																		<input type="text" name="dealer_id" value="" id="dealer_id" style="display:none">
																		<input type="text" name="dealer_company" value="" id="dealer_company" style="display:none">
																		<input type="text" name="package" value="10" id="package" style="display:none">
																	</div>
																</div>
															</div>
														</div>
													</div>
												</div>
											</div>
											<div class="col-md-12">
											<div class="footer">
												<div class="footer-inner">
													<div class="pull-right">
														<a href="">
															<input type="button" class="btn btn-next" name="next" value="Submit" style="background-color: orangered; display: inline-block;">
															<input type="button" id="save-data" class="btn btn-finish" data-loading-text="Please Wait..." name="finish" value="Submit" style="display: none;">
														</a>
													</div>
													<div class="pull-left">
														<a href="{{url('Residential/form3')}}">
															<input type="button" class="btn btn-previous" id="save-data" name="previous" value="Previous" style="background-color: grey;">
														</a>
													</div>
													<div class="clearfix"></div>
												</div>
											</div>
										</div>
										</form>
										@endforeach
									</div>
								</div>	
							</section>
						</div>
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						<a class="nomargin btn btn-default" href="#" style="width: 230px;">
							Read FAQ
						</a>
						<a style="width:230px" href="#" class="nomargin btn btn-default">
							Write to us
						</a>
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				</div>
			</div>
		</section>
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	<div class="footer-callout">
	</div>
	<footer id="colophon" class="site-footer footer" role="contentinfo">
		<div class="container footer-inner">
			<div class="row">
				<div class="footer-widget-area">
					<div class="col-md-6 col-md-3 footer-widget" role="complementary">
						<div class="widget widget_nav_menu" id="nav_menu-3">
							<h2 class="widget-title">Overview</h2>
							<div class="menu-main-container">
								<ul id="menu-main" class="menu">
									<li class="menu-item menu-item-type-post_type menu-item-object-page menu-item-16">
										<a href="#">Residential</a>
									</li>
									<li class="menu-item menu-item-type-post_type menu-item-object-page menu-item-15">
										<a href="#">Business</a>
									</li>
									<li class="menu-item menu-item-type-post_type menu-item-object-page menu-item-14">
										<a href="#/">Our Story</a>
									</li>
									<li class="menu-item menu-item-type-post_type menu-item-object-page menu-item-13">
										<a href="#">Support</a>
									</li>
									<li class="menu-item menu-item-type-post_type menu-item-object-page menu-item-12">
										<a href="#">Contact Us</a>
									</li>
								</ul>
							</div>
						</div>
					</div>
					<div class="col-md-3 col-sm-6 footer-widget" role="complementary">
						<div id="nav_menu-2" class="widget widget_nav_menu">
							<h2 class="widget-title">Legal</h2>
							<div class="menu-footer-2-container">
								<ul id="menu-footer-2" class="menu">
									<li id="menu-item-22" class="menu-item menu-item-type-post_type menu-item-object-page menu-item-22">
										<a href="#">Terms &amp; Conditions</a>
									</li>
									<li id="menu-item-373" class="menu-item menu-item-type-post_type menu-item-object-page menu-item-373">
										<a href="#">Privacy Policy</a>
									</li>
								</ul>
							</div>
						</div>
					</div>
					<div class="col-md-3 col-sm-6 footer-widget" role="complementary">
						<div id="text-2" class="widget widget_text">
							<h2 class="widget-title">Hotline</h2>			
							<div class="textwidget"><span class="number-big yellow">1300-38-8000</span></div>
						</div>	
					</div>
					<div class="col-md-3 col-sm-6 footer-widget" role="complementary">
						<div id="text-4" class="widget widget_text">
							<h2 class="widget-title">We Accept</h2>	
							<div class="textwidget"><img src=""></div>
						</div>
					</div>
				</div>
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		<div class="container">
			<div class="lowerfooter">
				<img width="50px" src="{{url('assets/logo/footerlogo.png')}}" align="left">
				<span class="lower-disclaimer">Copyright © 2017 Allo Technology Sdn Bhd. All rights reserved.</span>
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		</div>
	</footer>
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	<!-- Boostrap Wizard -->
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	<!-- DatePicker -->
	<script src="https://cdnjs.cloudflare.com/ajax/libs/bootstrap-datepicker/1.8.0/js/bootstrap-datepicker.min.js" type="text/javascript"></script>
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	<script src="{{url('js/signature_pad.ums.js')}}" type="text/javascript"></script>

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