@extends('layouts.frontend.master')

@section('content')

	<!-- Signup -->
    <section class="g-bg-gray-light-v5">
      	<div class="container g-py-50">

	        <div class="row justify-content-center">
				<div class="col-sm-10 col-md-9 col-lg-6">

					<div class="u-shadow-v21 g-bg-white rounded g-py-40 g-px-30">
						<header class="text-center mb-4">
							<h2 class="h2 g-color-black ">
								ពាក្យស្នើសុំប្រឡងប្រណាំង <br/> " ភោជនីយដ្ឋាន អាហារដ្ឋានទេសចរណ៍បម្រើម្ហូបខ្មែរឆ្នើម " ប្រចាំឆ្នាំ ២០១៨
							</h2>
						</header>

						<!-- Form -->
						<form class="g-py-15" action="{{ route('home.index') }}" method="post" enctype="multipart/form-data" autocomplete="off">

							<hr class="g-brd-gray-light-v4 g-mx-minus-30">

							<h4 class="h4 g-font-weight-700 g-mb-20">
								<i class="fa fa-user-circle fa-lg fa-fw"></i> អំពីអ្នកស្នើសុំ
							</h4>

							<div class="row">
								<div class="col-xs-12 col-sm-6 mb-4 flexibled-error">
									<label class="g-color-gray-dark-v2 g-font-size-15">ឈ្មោះ ( ជាភាសាខ្មែរ )</label>
									<input class="form-control g-color-black g-bg-white g-bg-white--focus g-brd-gray-light-v4 g-brd-primary--hover rounded g-py-15 g-px-15" type="text" name="kh_name" value="{{ old('kh_name') }}">
									@if($errors->has('kh_name'))
										<div class="error-badge" id="for-kh_name">
											{!! Helper::alert('danger', $errors->first('kh_name')) !!}
										</div>
									@endif
								</div>

								<div class="col-xs-12 col-sm-6 mb-4 flexibled-error">
									<label class="g-color-gray-dark-v2 g-font-size-15">ឈ្មោះ ( ឡាតាំង )</label>
									<input class="form-control g-color-black g-bg-white g-bg-white--focus g-brd-gray-light-v4 g-brd-primary--hover rounded g-py-15 g-px-15" type="text" name="en_name" value="{{ old('en_name') }}">
									@if($errors->has('en_name'))
										<div class="error-badge" id="for-en_name">
											{!! Helper::alert('danger', $errors->first('en_name')) !!}
										</div>
									@endif
								</div>
							</div>

							<div class="row">
								<div class="col-xs-12 col-sm-6 mb-4 flexibled-error">
									<label class="g-color-gray-dark-v2 g-font-size-15">ថ្ងៃ ខែ ឆ្នាំ កំណើត</label>
									<input class="form-control g-color-black g-bg-white g-bg-white--focus g-brd-gray-light-v4 g-brd-primary--hover rounded g-py-15 g-px-15 ofdob" type="text" name="dob" value="{{ old('dob') }}">
									@if($errors->has('dob'))
										<div class="error-badge" id="for-dob">
											{!! Helper::alert('danger', $errors->first('dob')) !!}
										</div>
									@endif
								</div>

								<div class="col-xs-12 col-sm-6 mb-4 flexibled-error">
									<label class="g-color-gray-dark-v2 g-font-size-15">ភេទ</label>
									<select class="js-custom-select w-100 u-select-v2 g-color-black g-brd-primary--hover g-bg-white rounded g-pl-15 g-py-15"
										data-placeholder="ជ្រើសរើស" data-open-icon="fa fa-angle-down" data-close-icon="fa fa-angle-up" name="gender">
								          	<option value=""></option>
								          	@foreach($gender as $value)
								          		@if( old('gender') == $value->term_id )
								          			<option class="g-brd-secondary-light-v2 g-color-black g-color-white--active g-bg-primary--active" value="{{ $value->term_id }}" selected="true">{{ $value->title }}</option>
								          		@else
								          			<option class="g-brd-secondary-light-v2 g-color-black g-color-white--active g-bg-primary--active" value="{{ $value->term_id }}">{{ $value->title }}</option>
								          		@endif
								          	@endforeach
							        </select>
							        @if($errors->has('gender'))
										<div class="error-badge" id="for-gender">
											{!! Helper::alert('danger', $errors->first('gender')) !!}
										</div>
									@endif
								</div>
							</div>

							<div class="row">
								<div class="col-xs-12 col-sm-6 mb-4 flexibled-error">
									<label class="g-color-gray-dark-v2 g-font-size-15">សញ្ជាតិ</label>
									<input class="form-control g-color-black g-bg-white g-bg-white--focus g-brd-gray-light-v4 g-brd-primary--hover rounded g-py-15 g-px-15" type="text" name="nationality" value="{{ old('nationality') }}">
									@if($errors->has('nationality'))
										<div class="error-badge" id="for-nationality">
											{!! Helper::alert('danger', $errors->first('nationality')) !!}
										</div>
									@endif
								</div>

								<div class="col-xs-12 col-sm-6 mb-4 flexibled-error">
									<label class="g-color-gray-dark-v2 g-font-size-15">មុខងារ</label>
									<input class="form-control g-color-black g-bg-white g-bg-white--focus g-brd-gray-light-v4 g-brd-primary--hover rounded g-py-15 g-px-15" type="text" name="function" value="{{ old('function') }}">
									@if($errors->has('function'))
										<div class="error-badge" id="for-function">
											{!! Helper::alert('danger', $errors->first('function')) !!}
										</div>
									@endif
								</div>
							</div>

							<div class="mb-4 flexibled-error">
								<label class="g-color-gray-dark-v2 g-font-size-15">អាសយដ្ឋានបច្ចុប្បន្ន</label>
								<input class="form-control g-color-black g-bg-white g-bg-white--focus g-brd-gray-light-v4 g-brd-primary--hover rounded g-py-15 g-px-15" type="text" name="address" value="{{ old('address') }}">
								@if($errors->has('address'))
									<div class="error-badge" id="for-address">
										{!! Helper::alert('danger', $errors->first('address')) !!}
									</div>
								@endif
							</div>

							<hr class="g-brd-gray-light-v4 g-mx-minus-30">

							<h4 class="h4 g-font-weight-700 g-mb-20">
								<i class="fa fa-info fa-lg fa-fw"></i> អំពីភោជនីយដ្ខាន
							</h4>

							<div class="mb-4 flexibled-error">
								<label class="g-color-gray-dark-v2 g-font-size-15">ឈ្មោះភោជនីយដ្ឋាន អាហារដ្ឋានទេសចរណ៍</label>
								<input class="form-control g-color-black g-bg-white g-bg-white--focus g-brd-gray-light-v4 g-brd-primary--hover rounded g-py-15 g-px-15" type="text" name="restaurant" value="{{ old('restaurant') }}">
								@if($errors->has('restaurant'))
									<div class="error-badge" id="for-restaurant">
										{!! Helper::alert('danger', $errors->first('restaurant')) !!}
									</div>
								@endif
							</div>

							<div class="row">
								<div class="col-xs-12 col-sm-6 mb-4 flexibled-error">
									<label class="g-color-gray-dark-v2 g-font-size-15">អាសយដ្ឋានលេខ</label>
									<input class="form-control g-color-black g-bg-white g-bg-white--focus g-brd-gray-light-v4 g-brd-primary--hover rounded g-py-15 g-px-15" type="text" name="house" value="{{ old('house') }}">
									@if($errors->has('house'))
										<div class="error-badge" id="for-house">
											{!! Helper::alert('danger', $errors->first('house')) !!}
										</div>
									@endif
								</div>

								<div class="col-xs-12 col-sm-6 mb-4 flexibled-error">
									<label class="g-color-gray-dark-v2 g-font-size-15">ផ្លូវលេខ</label>
									<input class="form-control g-color-black g-bg-white g-bg-white--focus g-brd-gray-light-v4 g-brd-primary--hover rounded g-py-15 g-px-15" type="text" name="street" value="{{ old('street') }}">
									@if($errors->has('street'))
										<div class="error-badge" id="for-street">
											{!! Helper::alert('danger', $errors->first('street')) !!}
										</div>
									@endif
								</div>
							</div>

							<div class="row">
								<div class="col-xs-12 col-sm-6 mb-4 flexibled-error">
									<label class="g-color-gray-dark-v2 g-font-size-15">ភូមិ</label>
									<input class="form-control g-color-black g-bg-white g-bg-white--focus g-brd-gray-light-v4 g-brd-primary--hover rounded g-py-15 g-px-15" type="text" name="village" value="{{ old('village') }}">
									@if($errors->has('village'))
										<div class="error-badge" id="for-village">
											{!! Helper::alert('danger', $errors->first('village')) !!}
										</div>
									@endif
								</div>

								<div class="col-xs-12 col-sm-6 mb-4 flexibled-error">
									<label class="g-color-gray-dark-v2 g-font-size-15">ឃុំ-សង្កាត់</label>
									<input class="form-control g-color-black g-bg-white g-bg-white--focus g-brd-gray-light-v4 g-brd-primary--hover rounded g-py-15 g-px-15" type="text" name="commune" value="{{ old('commune') }}">
									@if($errors->has('commune'))
										<div class="error-badge" id="for-commune">
											{!! Helper::alert('danger', $errors->first('commune')) !!}
										</div>
									@endif
								</div>
							</div>

							<div class="row">
								<div class="col-xs-12 col-sm-6 mb-4 flexibled-error">
									<label class="g-color-gray-dark-v2 g-font-size-15">ស្រុក-ខណ្ឌ-ក្រុង</label>
									<input class="form-control g-color-black g-bg-white g-bg-white--focus g-brd-gray-light-v4 g-brd-primary--hover rounded g-py-15 g-px-15" type="text" name="district" value="{{ old('district') }}">
									@if($errors->has('district'))
										<div class="error-badge" id="for-district">
											{!! Helper::alert('danger', $errors->first('district')) !!}
										</div>
									@endif
								</div>

								<div class="col-xs-12 col-sm-6 mb-4 flexibled-error">
									<label class="g-color-gray-dark-v2 g-font-size-15">រាជធានី-ខេត្ត</label>
									<input class="form-control g-color-black g-bg-white g-bg-white--focus g-brd-gray-light-v4 g-brd-primary--hover rounded g-py-15 g-px-15" type="text" name="province" value="{{ old('province') }}">
									@if($errors->has('province'))
										<div class="error-badge" id="for-province">
											{!! Helper::alert('danger', $errors->first('province')) !!}
										</div>
									@endif
								</div>
							</div>

							<div class="row">
								<div class="col-xs-12 col-sm-6 mb-4 flexibled-error">
									<label class="g-color-gray-dark-v2 g-font-size-15">ទូរស័ព្ទ</label>
									<input class="form-control g-color-black g-bg-white g-bg-white--focus g-brd-gray-light-v4 g-brd-primary--hover rounded g-py-15 g-px-15" type="text" name="phone" value="{{ old('phone') }}">
									@if($errors->has('phone'))
										<div class="error-badge" id="for-phone">
											{!! Helper::alert('danger', $errors->first('phone')) !!}
										</div>
									@endif
								</div>

								<div class="col-xs-12 col-sm-6 mb-4 flexibled-error">
									<label class="g-color-gray-dark-v2 g-font-size-15">ទូរសារ</label>
									<input class="form-control g-color-black g-bg-white g-bg-white--focus g-brd-gray-light-v4 g-brd-primary--hover rounded g-py-15 g-px-15" type="text" name="fax" value="{{ old('fax') }}">
									@if($errors->has('fax'))
										<div class="error-badge" id="for-fax">
											{!! Helper::alert('danger', $errors->first('fax')) !!}
										</div>
									@endif
								</div>
							</div>

							<div class="row">
								<div class="col-xs-12 col-sm-6 mb-4 flexibled-error">
									<label class="g-color-gray-dark-v2 g-font-size-15">អ៊ីមែល</label>
									<input class="form-control g-color-black g-bg-white g-bg-white--focus g-brd-gray-light-v4 g-brd-primary--hover rounded g-py-15 g-px-15" type="email" name="email" value="{{ old('email') }}">
									@if($errors->has('email'))
										<div class="error-badge" id="for-email">
											{!! Helper::alert('danger', $errors->first('email')) !!}
										</div>
									@endif
								</div>

								<div class="col-xs-12 col-sm-6 mb-4 flexibled-error">
									<label class="g-color-gray-dark-v2 g-font-size-15">វេបសាយ</label>
									<input class="form-control g-color-black g-bg-white g-bg-white--focus g-brd-gray-light-v4 g-brd-primary--hover rounded g-py-15 g-px-15" type="text" name="website" value="{{ old('website') }}">
									@if($errors->has('website'))
										<div class="error-badge" id="for-website">
											{!! Helper::alert('danger', $errors->first('website')) !!}
										</div>
									@endif
								</div>
							</div>

							<hr class="g-brd-gray-light-v4 g-mx-minus-30">

							<h4 class="h4 g-font-weight-700 g-mb-20">
								<i class="fa fa-file-pdf-o fa-lg fa-fw"></i> សូមភ្ជាប់ឯកសារតម្រូវ
							</h4>

							<div class="mb-4">
								<div class="form-group mb-0 flexibled-error">
				                  	<p class="g-font-size-15">បញ្ជីរាយនាមមុខម្ងូបខ្មែរ</p>
				                  	<label class="u-file-attach-v2 g-color-gray-dark-v5 mb-0">
					                    <input name="menu" type="file">
					                    <i class="icon-cloud-upload g-font-size-16 g-pos-rel g-top-2 g-mr-5"></i>
					                    <span class="js-value">Attach file</span>
				                  	</label>
				                  	@if($errors->has('menu'))
										<div class="error-badge" id="for-menu">
											{!! Helper::alert('danger', $errors->first('menu')) !!}
										</div>
									@endif
				                </div>
							</div>

							<div class="mb-4">
								<div class="form-group mb-0 flexibled-error">
				                  	<p class="g-font-size-15">អាជ្ញាបណ្ណទេសចរណ៍មានសុពលភាព</p>
				                  	<label class="u-file-attach-v2 g-color-gray-dark-v5 mb-0">
					                    <input name="license" type="file">
					                    <i class="icon-cloud-upload g-font-size-16 g-pos-rel g-top-2 g-mr-5"></i>
					                    <span class="js-value">Attach file</span>
				                  	</label>
				                  	@if($errors->has('license'))
										<div class="error-badge" id="for-license">
											{!! Helper::alert('danger', $errors->first('license')) !!}
										</div>
									@endif
				                </div>
							</div>

							<hr class="g-brd-gray-light-v4 g-mx-minus-30">

							<div class="row justify-content-between mb-4">
								<div class="col-4 align-self-center">
									{{ csrf_field() }}
									<button class="btn btn-md u-btn-primary rounded g-py-13 g-px-25" type="submit">Send</button>
								</div>
							</div>

						</form>
						<!-- End Form -->

					</div>

				</div>
	        </div>

      	</div>
    </section>
    <!-- End Signup -->

@endsection

@section('script')
	<script src="{{ asset('assets/frontend/js/helpers/hs.file-attachments.js') }}"></script>
	<script>
		$(document).on('ready', function () {
			// initialization of forms
			$.HSCore.helpers.HSFileAttachments.init();
		});
	</script>
@endsection