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PHP Version:

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User:

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✏️ Editing: medilink.php

<?php
ob_start();
session_start();
include("includes/inall.php");
if(!isset($_SESSION['duplblock']) && $_SESSION['duplblock']=="") {
	$_SESSION['duplblock']=strtotime("now");
}
function SMS_Sender($mobile_number,$message_det) {
	$curl=curl_init();
	curl_setopt_array($curl,array(
		CURLOPT_URL=>"https://api.msg91.com/api/v2/sendsms",
		CURLOPT_RETURNTRANSFER=>true,
		CURLOPT_ENCODING=>"",
		CURLOPT_MAXREDIRS=>10,
		CURLOPT_TIMEOUT=>30,
		CURLOPT_HTTP_VERSION=>CURL_HTTP_VERSION_1_1,
		CURLOPT_CUSTOMREQUEST=>"POST",
		CURLOPT_POSTFIELDS=>"{ \"sender\": \"CCADMS\", \"route\": \"4\", \"country\": \"91\", \"sms\": [ { \"message\": \"".$message_det."\", \"to\": [ \"".$mobile_number."\" ] } ] }",
		CURLOPT_SSL_VERIFYHOST=>0,
		CURLOPT_SSL_VERIFYPEER=>0,
		CURLOPT_HTTPHEADER=>array(
		"authkey:261846ALkgB0xvZ5c5c4e87",
		"content-type:application/json"
	),
	));
	$response=curl_exec($curl);
	$err=curl_error($curl);
	curl_close($curl);
	if ($err) {
		echo "cURL Error #:" . $err;
	} else {
		echo $response;
	}
}
function findid() {
	//$newid="CCAD".rand(100002,999999);
	$newid=rand(100002,999999);
	$resa=mysqli_query($_SESSION['concton'],"select * from `registration` where `cusid`='".$newid."'");
	$resb=mysqli_query($_SESSION['concton'],"select * from `medilink` where `cusid`='".$newid."'");
	if(mysqli_num_rows($resa)<1 && mysqli_num_rows($resb)<1) {
		$cusid=$newid;
	} else {
		$cusid=findid();
	}
	return $cusid;
}
function findpid() {
	$newid="CJN".rand(111111,999999);
	$resa=mysqli_query($_SESSION['concton'],"select * from `orderp` where `or_id`='".$newid."'");
	if(mysqli_num_rows($resa)<1) {
		$pid=$newid;
	} else {
		$pid=findpid();
	}
	return $pid;
}
if(isset($_POST['submitin']) && $_POST['submitin']=="Register") {
	$d=date("Y-m-d");
	$pfname=isset($_POST['pfname'])?addslashes(strtoupper(trim($_POST['pfname']))):'';
	$plname=isset($_POST['plname'])?addslashes(strtoupper(trim($_POST['plname']))):'';
	$bname=isset($_POST['bname'])?addslashes(strtoupper(trim($_POST['bname']))):'';
	$branch=isset($_POST['branch'])?addslashes(strtoupper(trim($_POST['branch']))):'';
	$accno=isset($_POST['accno'])?addslashes(strtoupper(trim($_POST['accno']))):'';
	$ifsc=isset($_POST['ifsc'])?addslashes(strtoupper(trim($_POST['ifsc']))):'';
	$fname=isset($_POST['fname'])?addslashes(strtoupper(trim($_POST['fname']))):'';
	$lname=isset($_POST['lname'])?addslashes(strtoupper(trim($_POST['lname']))):'';
	$dob=isset($_POST['dob'])?addslashes(trim($_POST['dob'])):'';
	$gender=isset($_POST['gender'])?addslashes(strtoupper(trim($_POST['gender']))):'';
	$fname2=isset($_POST['fname2'])?addslashes(strtoupper(trim($_POST['fname2']))):'';
	$lname2=isset($_POST['lname2'])?addslashes(strtoupper(trim($_POST['lname2']))):'';
	$dob2=isset($_POST['dob2'])?addslashes(trim($_POST['dob2'])):'';
	$gender2=isset($_POST['gender2'])?addslashes(strtoupper(trim($_POST['gender2']))):'';
	$fname3=isset($_POST['fname3'])?addslashes(strtoupper(trim($_POST['fname3']))):'';
	$lname3=isset($_POST['lname3'])?addslashes(strtoupper(trim($_POST['lname3']))):'';
	$dob3=isset($_POST['dob3'])?addslashes(trim($_POST['dob3'])):'';
	$gender3=isset($_POST['gender3'])?addslashes(strtoupper(trim($_POST['gender3']))):'';
	$fname4=isset($_POST['fname4'])?addslashes(strtoupper(trim($_POST['fname4']))):'';
	$lname4=isset($_POST['lname4'])?addslashes(strtoupper(trim($_POST['lname4']))):'';
	$dob4=isset($_POST['dob4'])?addslashes(trim($_POST['dob4'])):'';
	$gender4=isset($_POST['gender4'])?addslashes(strtoupper(trim($_POST['gender4']))):'';
	$fname5=isset($_POST['fname5'])?addslashes(strtoupper(trim($_POST['fname5']))):'';
	$lname5=isset($_POST['lname5'])?addslashes(strtoupper(trim($_POST['lname5']))):'';
	$dob5=isset($_POST['dob5'])?addslashes(trim($_POST['dob5'])):'';
	$gender5=isset($_POST['gender5'])?addslashes(strtoupper(trim($_POST['gender5']))):'';
	$fname6=isset($_POST['fname6'])?addslashes(strtoupper(trim($_POST['fname6']))):'';
	$lname6=isset($_POST['lname6'])?addslashes(strtoupper(trim($_POST['lname6']))):'';
	$dob6=isset($_POST['dob6'])?addslashes(trim($_POST['dob6'])):'';
	$gender6=isset($_POST['gender6'])?addslashes(strtoupper(trim($_POST['gender6']))):'';
	$idno=isset($_POST['idno'])?addslashes(trim($_POST['idno'])):'';
	$mobile=isset($_POST['mobile'])?addslashes(trim($_POST['mobile'])):'';
	$amobile=isset($_POST['amobile'])?addslashes(trim($_POST['amobile'])):'';
	$email=isset($_POST['email'])?addslashes(trim($_POST['email'])):'';
	$panad=isset($_POST['panad'])?addslashes(trim($_POST['panad'])):'';
	$addresslinea=isset($_POST['addresslinea'])?addslashes(strtoupper(trim($_POST['addresslinea']))):'';
	$addresslineb=isset($_POST['addresslineb'])?addslashes(strtoupper(trim($_POST['addresslineb']))):'';
	$state=isset($_POST['state'])?addslashes(strtoupper(trim($_POST['state']))):'';
	$district=isset($_POST['district'])?addslashes(strtoupper(trim($_POST['district']))):'';
	$city=isset($_POST['city'])?addslashes(strtoupper(trim($_POST['city']))):'';
	$area=isset($_POST['area'])?addslashes(strtoupper(trim($_POST['area']))):'';
	$pin=isset($_POST['pin'])?addslashes(trim($_POST['pin'])):'';
	$product=isset($_POST['product'])?addslashes(trim($_POST['product'])):'';
	$newid=findid();
	$pid=findpid();
	$resa=mysqli_query($con,"select * from `medilink` where `cusid`='".$newid."'");
	if(mysqli_num_rows($resa)<1) {
		$insert_sql_data=array('date'=>$d,
		'cusid'=>$newid,
		'pfname'=>$pfname,
		'plname'=>$plname,
		'branch'=>$branch,
		'ifsc'=>$ifsc,
		'fname'=>$fname,
		'fname'=>$fname,
		'fname'=>$fname,
		'lname'=>$lname,
		'dob'=>$dob,
		'gender'=>$gender,
		'fname2'=>$fname2,
		'lname2'=>$lname2,
		'dob2'=>$dob2,
		'gender2'=>$gender2,
		'fname3'=>$fname3,
		'lname3'=>$lname3,
		'dob3'=>$dob3,
		'gender3'=>$gender3,
		'fname4'=>$fname4,
		'lname4'=>$lname4,
		'dob4'=>$dob4,
		'gender4'=>$gender4,
		'fname5'=>$fname5,
		'lname5'=>$lname5,
		'dob5'=>$dob5,
		'gender5'=>$gender5,
		'fname6'=>$fname6,
		'lname6'=>$lname6,
		'dob6'=>$dob6,
		'gender6'=>$gender6,
		'mobile'=>$mobile,
		'amobile'=>$amobile,
		'email'=>$email,
		'panad'=>$panad,
		'addresslinea'=>$addresslinea,
		'addresslineb'=>$addresslineb,
		'state'=>$state,
		'district'=>$district,
		'city'=>$city,
		'area'=>$area,
		'pin'=>$pin,
		'product'=>$product,
		'addedby'=>$_SESSION['rcusid'],
		'status'=>'1',
		'duplblock'=>$_SESSION['duplblock'],
		'paymentid'=>$pid
		);
		$ins_query=tep_db_perform("medilink",$insert_sql_data,"insert");
        $id=mysqli_insert_id($con);
		if(isset($_FILES['ppan']['name']) && $_FILES['ppan']['name']!="") {
			$userfile_name=$_FILES['pppanan']['name'];
			$userfile_tmp=$_FILES['ppan']['tmp_name'];
			$img=$_FILES['ppan']['tmp_name'];
			$userfile_size=$_FILES['ppan']['size'];
			$userfile_type=$_FILES['ppan']['type'];
			$t=explode("/",$userfile_type);
			if($t[0]=="image") {
				$path=time().$userfile_name; //original path
				$uppath="kyc/".$path;
				move_uploaded_file($_FILES['ppan']['tmp_name'],$uppath);
			}
			$insert_sql_data=array('ppan'=>$path);
			tep_db_perform("medilink",$insert_sql_data,'update',"reg_id='".(int)$id."'");	
		}
		if(isset($_FILES['paadhaar']['name']) && $_FILES['paadhaar']['name']!="") {
			$userfile_name=$_FILES['paadhaar']['name'];
			$userfile_tmp=$_FILES['paadhaar']['tmp_name'];
			$img=$_FILES['paadhaar']['tmp_name'];
			$userfile_size=$_FILES['paadhaar']['size'];
			$userfile_type=$_FILES['paadhaar']['type'];
			$t=explode("/",$userfile_type);
			if($t[0]=="image") {
				$path=time().$userfile_name; //original path
				$uppath="kyc/".$path;
				move_uploaded_file($_FILES['paadhaar']['tmp_name'],$uppath);
			}
			$insert_sql_data=array('paadhaar'=>$path);
			tep_db_perform("medilink",$insert_sql_data,'update',"reg_id='".(int)$id."'");	
		}
		if(isset($_FILES['pphoto']['name']) && $_FILES['pphoto']['name']!="") {
			$userfile_name=$_FILES['pphoto']['name'];
			$userfile_tmp=$_FILES['pphoto']['tmp_name'];
			$img=$_FILES['pphoto']['tmp_name'];
			$userfile_size=$_FILES['pphoto']['size'];
			$userfile_type=$_FILES['pphoto']['type'];
			$t=explode("/",$userfile_type);
			if($t[0]=="image") {
				$path=time().$userfile_name; //original path
				$uppath="kyc/".$path;
				move_uploaded_file($_FILES['pphoto']['tmp_name'],$uppath);
			}
			$insert_sql_data=array('pphoto'=>$path);
			tep_db_perform("medilink",$insert_sql_data,'update',"reg_id='".(int)$id."'");	
		}
		if(isset($_FILES['pbankproof']['name']) && $_FILES['pbankproof']['name']!="") {
			$userfile_name=$_FILES['pbankproof']['name'];
			$userfile_tmp=$_FILES['pbankproof']['tmp_name'];
			$img=$_FILES['pbankproof']['tmp_name'];
			$userfile_size=$_FILES['pbankproof']['size'];
			$userfile_type=$_FILES['pbankproof']['type'];
			$t=explode("/",$userfile_type);
			if($t[0]=="image") {
				$path=time().$userfile_name; //original path
				$uppath="kyc/".$path;
				move_uploaded_file($_FILES['pbankproof']['tmp_name'],$uppath);
			}
			$insert_sql_data=array('pbankproof'=>$path);
			tep_db_perform("medilink",$insert_sql_data,'update',"reg_id='".(int)$id."'");	
		}
		if(isset($_FILES['ageprf']['name']) && $_FILES['ageprf']['name']!="") {
			$userfile_name=$_FILES['ageprf']['name'];
			$userfile_tmp=$_FILES['ageprf']['tmp_name'];
			$img=$_FILES['ageprf']['tmp_name'];
			$userfile_size=$_FILES['ageprf']['size'];
			$userfile_type=$_FILES['ageprf']['type'];
			$t=explode("/",$userfile_type);
			if($t[0]=="image") {
				$path=time().$userfile_name; //original path
				$uppath="kyc/".$path;
				move_uploaded_file($_FILES['ageprf']['tmp_name'],$uppath);
			}
			$insert_sql_data=array('ageprf'=>$path);
			tep_db_perform("medilink",$insert_sql_data,'update',"reg_id='".(int)$id."'");	
		}
		if(isset($_FILES['idprf']['name']) && $_FILES['idprf']['name']!="") {
			$userfile_name=$_FILES['idprf']['name'];
			$userfile_tmp=$_FILES['idprf']['tmp_name'];
			$img=$_FILES['idprf']['tmp_name'];
			$userfile_size=$_FILES['idprf']['size'];
			$userfile_type=$_FILES['idprf']['type'];
			$t=explode("/",$userfile_type);
			if($t[0]=="image") {
				$path=time().$userfile_name; //original path
				$uppath="kyc/".$path;
				move_uploaded_file($_FILES['idprf']['tmp_name'],$uppath);
			}
			$insert_sql_data=array('idprf'=>$path);
			tep_db_perform("medilink",$insert_sql_data,'update',"reg_id='".(int)$id."'");	
		}
		if(isset($_FILES['photo']['name']) && $_FILES['photo']['name']!="") {
			$userfile_name=$_FILES['photo']['name'];
			$userfile_tmp=$_FILES['photo']['tmp_name'];
			$img=$_FILES['photo']['tmp_name'];
			$userfile_size=$_FILES['photo']['size'];
			$userfile_type=$_FILES['photo']['type'];
			$t=explode("/",$userfile_type);
			if($t[0]=="image") {
				$path=time().$userfile_name; //original path
				$uppath="kyc/".$path;
				move_uploaded_file($_FILES['photo']['tmp_name'],$uppath);
			}
			$insert_sql_data=array('photo'=>$path);
			tep_db_perform("medilink",$insert_sql_data,'update',"reg_id='".(int)$id."'");	
		}
		if(isset($_FILES['audio']['name']) && $_FILES['audio']['name']!="") {
			$userfile_name=$_FILES['audio']['name'];
			$userfile_tmp=$_FILES['audio']['tmp_name'];
			$img=$_FILES['audio']['tmp_name'];
			$userfile_size=$_FILES['audio']['size'];
			$userfile_type=$_FILES['audio']['type'];
			$t=explode("/",$userfile_type);
			
			$path=time().$userfile_name; //original path
			$uppath="kyc/".$path;
			move_uploaded_file($_FILES['audio']['tmp_name'],$uppath);

$insert_sql_data=array('audio'=>$path);
			tep_db_perform("humsafar",$insert_sql_data,'update',"reg_id='".(int)$id."'");	
		}
	}	
	if($ins_query) {	
		$t=date("h:i:s A");
		if($_REQUEST['odate']!="") {
			$odate=$_REQUEST['odate'];
		}	
		if($odate=="") {
			$odate=date("Y-m-d");		
		}
		$disam=0;
		$ttax=0;
		$ship=0;	
		$name=$fname." ".$lname;
		$rowm=mysqli_fetch_array(mysqli_query($con,"select * from `products` where `pro_id`='".$product."'"));
		$amount=$rowm['price'];
		$insert_sql_data=array('or_gstname'=>$name,
		'or_gstaddress'=>$addresslinea,
		'or_gstcity'=>$city,
		'or_gstpin'=>$pin,
		'or_id'=>$pid,
		'or_inv_id'=>$pid,
		'or_category'=>'Gateway',
		'or_value'=>$amount,
		'or_discount'=>$disam,
		'or_gst'=>$ttax,
		'or_shipval'=>$ship,
		'or_net'=>$amount,
		'or_delmode'=>'Prepaid',
		'or_promo'=>'',
		'or_date'=>$odate,
		'or_time'=>$t,
		'orderstatus'=>'Order Work In Progress',
		'paymentstatus'=>'Not Done',
		'cusid'=>$id,
		'medilink'=>'Yes'
		);
		$ins_query=tep_db_perform("orderp",$insert_sql_data,"insert");
		$id=mysqli_insert_id($con);
		$nid=base64_encode($id);
		$insert_sql_data=array('orderpro_ref'=>$id,
		'orderpro_pro'=>$product,
		'orderpro_qty'=>'1',
		'orderpro_mrp'=>$amount,
		'orderpro_val'=>$amount,
		'status'=>'Order Work In Progress'
		);
		$ins_query=tep_db_perform("orderpro",$insert_sql_data,"insert");
	}	
	unset($_SESSION['duplblock']);
	header("location:medilinkpay.php?nid=".$nid);
	exit();
}
include("includes/headermain.php"); 
?>
<?php if($_SESSION['msg']) { ?>
	<script src="//ajax.googleapis.com/ajax/libs/jquery/1.11.1/jquery.js"></script>
	<script>
	$(document).ready(function() {	
		var id = '#dialog';
			
		//Get the screen height and width
		var maskHeight = $(document).height();
		var maskWidth = $(window).width();
			
		//Set heigth and width to mask to fill up the whole screen
		$('#mask').css({'width':maskWidth,'height':maskHeight});
	
		//transition effect
		$('#mask').fadeIn(500);	
		$('#mask').fadeTo("slow",0.9);	
			
		//Get the window height and width
		var winH = $(window).height();
		var winW = $(window).width();
					  
		//Set the popup window to center
		$(id).css('top',  winH/2-$(id).height()/2);
		$(id).css('left', winW/2-$(id).width()/2);
		
		//transition effect
		$(id).fadeIn(2000); 	
		
		//if close button is clicked
		$('.window .close').click(function (e) {
			//Cancel the link behavior
			e.preventDefault();
		
			$('#mask').hide();
			$('.window').hide();
		});
	
		//if mask is clicked
		$('#mask').click(function () {
			$(this).hide();
			$('.window').hide();
		});
	});
	</script>
	<style>
	#mask {
		position: absolute;
		left: 0;
		top: 0;
		z-index: 9000;
		display: none;
	}
	#boxes .window {
		position: absolute;
		left: 0;
		top: 0;
		width: 300px;
		height: 200px;
		display: none;
		z-index: 9999;
		padding: 20px;
		border-radius: 5px;
		text-align: center;
	}
	#boxes #dialog {
		width: 300px;
		height: 200px;
		padding: 10px;
		background: #F9F9F9;
		font-size: 16px;
		font-weight: bold;
		webkit-box-shadow: 0 0 10px #999999;
  		box-shadow: 0 0 10px #999999;
	}
	#popupfoot {
		position: absolute;
		margin: auto;
		bottom: 20px;
		color: #005CB9;
	}
	.close {
		font-size: 12px !important;
	}
	</style>
	<div id="boxes">
		<div id="dialog" class="window">
			<?php if($_SESSION['msg']) { ?><span><?php print $_SESSION['msg']; $_SESSION['msg']=""; ?></span><?php } ?>
			<?php if($_SESSION['msgerr']) { ?><span class="redtxt"><?php print $_SESSION['msgerr']; $_SESSION['msgerr']=""; ?></span><?php } ?>
			<div id="popupfoot"><a href="#" class="close">Close</a></div>
		</div>
		<div id="mask"></div>
	</div>
<?php } ?>
<body class="body-bg">


<div id="preloader">
	<div class="loader"></div>
</div>


<div class="horizontal-main-wrapper">
	<?php include("includes/header.php"); ?>
	
	<div class="main-content">
	 	<div class="main-content-inner">
			
			<div> 
				<div class="col-lg-12 mt-5">
					<div class="card">
						<div class="card-body">
							<h4 class="header-title titlebg">Medilink</h4>
							<form action="#" method="post" name="rform" enctype="multipart/form-data">
								<input type="hidden" name="submitin" value="Register">
								<?php /*?><?php if($_SESSION['msgerr']) { ?><span class="redtxt"><?php print $_SESSION['msgerr']; $_SESSION['msgerr']=""; ?></span><div class="cleaner h10"></div><?php } ?>
								<?php if($_SESSION['msg']) { ?><span class="grtxt"><?php print $_SESSION['msg']; $_SESSION['msg']=""; ?></span><div class="cleaner h10"></div><?php } ?><?php */?>
								<?php /*?><div class="form-group">
									<label for="example-text-input" class="col-form-label">SPONSOR</label> <strong><?php print $_SESSION['rcusid']; ?></strong>
								</div><?php */?>
								
								<h4 class="header-title titlebg">Proposer Details</h4>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span></span>First Name</label>
									<input class="form-control" type="text" name="pfname" id="pfname" autocomplete="off">
								</div>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span></span>Last Name</label>
									<input class="form-control" type="text" name="plname" id="plname" autocomplete="off">
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span></span>Bank Name</label>
									<input class="form-control" type="text" name="bname" id="bname" autocomplete="off">
								</div>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span></span>Branch</label>
									<input class="form-control" type="text" name="branch" id="branch" autocomplete="off">
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span></span>Acc No.</label>
									<input class="form-control" type="text" name="accno" id="accno" autocomplete="off">
								</div>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span></span>IFSC</label>
									<input class="form-control" type="text" name="ifsc" id="ifsc" autocomplete="off">
								</div>
								<div class="cleaner h20"></div>
								<h4 class="header-title titlebg">KYC Details of Proposer</h4>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span></span>Upload PAN</label>
									<input class="form-control" type="file" name="ppan" id="ppan">
								</div>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span></span>Upload Aadhaar</label>
									<input class="form-control" type="file" name="paadhaar" id="paadhaar">
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span></span>Upload Photo</label>
									<input class="form-control" type="file" name="pphoto" id="pphoto">
								</div>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span></span>Upload Bank Proof</label>
									<input class="form-control" type="file" name="pbankproof" id="pbankproof">
								</div>
								<div class="cleaner h20"></div>
								<h4 class="header-title titlebg">Details of User 1</h4>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>First Name</label>
									<input class="form-control" type="text" name="fname" id="fname" autocomplete="off" required>
								</div>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>Last Name</label>
									<input class="form-control" type="text" name="lname" id="lname" autocomplete="off" required>
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>DOB</label>
									<input class="form-control" type="date" name="dob" id="dob" autocomplete="off" pattern="dd-mm-yyyy" required>
								</div>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>Gender</label>
									<select class="form-control spslc" name="gender" id="gender" autocomplete="off" required>
										<option value="">Select
										<option value="Male">Male
										<option value="Female">Female
										<option value="Other">Other
									</select>
								</div>
								<?php for($i=2;$i<=6;$i++) { ?>
									<div class="cleaner h20"></div>
									<h4 class="header-title titlebg">Details of User <?php print $i; ?></h4>
									<div class="form-group col-md-6 floatleft">
										<label for="example-text-input" class="col-form-label"><span>*</span>First Name</label>
										<input class="form-control" type="text" name="fname<?php print $i; ?>" id="fname<?php print $i; ?>" autocomplete="off">
									</div>
									<div class="form-group col-md-6 floatleft">
										<label for="example-text-input" class="col-form-label"><span>*</span>Last Name</label>
										<input class="form-control" type="text" name="lname<?php print $i; ?>" id="lname<?php print $i; ?>" autocomplete="off">
									</div>
									<div class="cleaner"></div>
									<div class="form-group col-md-6 floatleft">
										<label for="example-text-input" class="col-form-label"><span>*</span>DOB</label>
										<input class="form-control" type="date" name="dob<?php print $i; ?>" id="dob<?php print $i; ?>" autocomplete="off" pattern="dd-mm-yyyy">
									</div>
									<div class="form-group col-md-6 floatleft">
										<label for="example-text-input" class="col-form-label"><span>*</span>Gender</label>
										<select class="form-control spslc" name="gender<?php print $i; ?>" id="gender<?php print $i; ?>" autocomplete="off">
											<option value="">Select
											<option value="Male">Male
											<option value="Female">Female
											<option value="Other">Other
										</select>
									</div>
								<?php } ?>	
								<?php /* ?><div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>ID No. (Voter/Aadhaar/PAN)</label>
									<input class="form-control" type="text" name="idno" id="idno" autocomplete="off" required>
								</div><?php */ ?>
								<div class="cleaner h20"></div>
								<h4 class="header-title titlebg">Contact Details</h4>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>Mobile No.</label>
									<input class="form-control" type="number" name="mobile" id="mobile" autocomplete="off" required>
									<div id="mbtxt"></div>
								</div>
								<?php /* ?><div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label">Whatsapp No.</label>
									<input class="form-control" type="number" name="amobile" id="amobile" autocomplete="off">
								</div><?php */ ?>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label">Email ID</label>
									<input class="form-control" type="email" name="email" id="email" autocomplete="off">
								</div>
								<div class="cleaner h20"></div>
								<h4 class="header-title titlebg">KYC Details</h4>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>PAN/Aadhaar No.</label>
									<input class="form-control" type="text" name="panad" id="panad" required>
								</div>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>Upload Age Proof</label>
									<input class="form-control" type="file" name="ageprf" id="ageprf" required>
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>Upload ID Proof</label>
									<input class="form-control" type="file" name="idprf" id="idprf" required>
								</div>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>Upload Photo</label>
									<input class="form-control" type="file" name="photo" id="photo" required>
								</div>
								<div class="cleaner h20"></div>
								<h4 class="header-title titlebg">Address Details</h4>
								<div class="form-group col-md-12 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>Address Line 1</label>
									<input class="form-control" type="text" name="addresslinea" id="addresslinea" autocomplete="off" required>
								</div>
								<div class="form-group col-md-12 floatleft">
									<label for="example-text-input" class="col-form-label">Address Line 2</label>
									<input class="form-control" type="text" name="addresslineb" id="addresslineb" autocomplete="off">
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>State</label>
									<select class="form-control spslc" name="state" id="state" onChange="fetchdistrict('disblock','district',this.value);" required>
										<option value="">Select
										<?php
										$resst=mysqli_query($con,"select distinct `state` from `statedis` where 1");
										while($rowst=mysqli_fetch_array($resst)) {
										?>
											<option value="<?php print $rowst['state']; ?>"><?php print $rowst['state']; ?>
										<?php } ?>	
									</select>
								</div>
								<div class="form-group col-md-6 floatleft" id="disblock">
									<label for="example-text-input" class="col-form-label"><span>*</span>District</label>
									<select class="form-control spslc" name="district" id="district" required>
										<option value="">Select
									</select>
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>City</label>
									<input class="form-control" type="text" name="city" id="city" autocomplete="off" required>
								</div>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>PIN</label>
									<input class="form-control" type="number" name="pin" id="pin" onBlur="checkpin('pin',this.value);" autocomplete="off" required>
									<div id="pintxt"></div>
								</div>
								<?php 
								if($_SESSION['rcusid']=="100001") {  
									$dt=date("Y-m-d");
								?>
									<div class="cleaner"></div>
									<div class="form-group col-md-3 floatleft">
										<label for="example-text-input" class="col-form-label"><span>*</span>Date</label>
										<input class="form-control" type="date" name="odate" id="odate" value="<?php print $dt; ?>" required>
									</div>
								<?php } ?>	
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>Upload Audio File</label>
									<input class="form-control" type="file" name="audio" id="audio" required>
								</div>
								<div class="cleaner h20"></div>
								<div class="form-group col-md-12 floatleft">
									<?php
									$resst=mysqli_query($con,"select * from `products` where `medilink`='yes'");
									while($rowst=mysqli_fetch_array($resst)) {
									?>
										<input type="radio" name="product" id="product" value="<?php print $rowst['pro_id']; ?>" required>&nbsp;<strong><?php print strtoupper($rowst['name']); ?></strong> - <?php print $rowst['price']; ?> - <?php print $rowst['features']; ?>
										<div class="cleaner"></div>
									<?php } ?>
									<div class="cleaner h20"></div>
									<input type="checkbox" name="finalsubmit" id="finalsubmit" value="Yes" required><div class="cleaner"></div>I hereby declare that all proposed members are in good health and entirely free from any mental or physical impairments or deformities, disease/condition. Neither any of the proposed members have been hospitalized for treatment of an illness or injury in past nor consulted any physician or conducted investigation for reasons other than common cough, cold or flu. None of the proposed member are habitual consumer of alcohol, tobacco, gutka or any recreational drugs.
								</div>
								<button id="sbutton" type="submit" class="btn btn-primary mt-4 pr-4 pl-4">Submit</button>
							</form>	
						</div>
					</div>
				</div>
			</div>
			
		</div>
	</div>
	
	<?php include("includes/footer.php"); ?>
</div>


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