@include('dashboard.layouts.header')

<!-- Content Wrapper. Contains page content -->
<div class="content-wrapper">
  <!-- Content Header (Page header) -->
  <section class="content-header">
    <div class="container-fluid">
      <div class="row mb-2">
        <div class="col-sm-6">
          <h1>Authorization to Dissolve an Entity</h1>
        </div>
        <div class="col-sm-6">
          <ol class="breadcrumb float-sm-right">
            <li class="breadcrumb-item"><a href="/dashboard">Home</a></li>
            <li class="breadcrumb-item active">Authorization to Dissolve an Entity</li>
          </ol>
        </div>
      </div>
    </div><!-- /.container-fluid -->
  </section>

  <!-- Main content -->
  <section class="content">
    <div class="container-fluid">
      <div class="row">
        <!-- left column -->
        <div class="col-md-12">
          <!-- general form elements -->
          <div class="card card-primary">
            <div class="card-header">
              <h3 class="card-title">Authorization to Dissolve an Entity</h3>
            </div>
            </br>
            @if (session('success'))
            <div class="alert alert-success">
              {{ session('success') }}
            </div>
            @endif
            @if(isset($report))
            <form action="{{ route('authorization-dissolve-entity-submit-form.update', $report->id) }}" method="POST" onsubmit="disableButton()">
              @csrf
              @method('PUT')
              @else
              <form action="{{ route('authorization-dissolve-entity-submit-form') }}" method="POST" onsubmit="disableButton()">
                @csrf
                @endif
                @csrf
                <div class="card-body">
                  <!-- Corporation Information -->
                  <h4>Corporation Information</h4>
                  <div class="row">
                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="corporationName">Corporation Name</label>
                        <input type="text" value="{{ old('corporation_name', $report->corporation_name ?? '') }}" class="form-control" name="corporation_name" id="corporationName" placeholder="Enter corporation name">
                        @error('corporation_name')
                        <span class="text-danger">{{ $message }}</span>
                        @enderror
                      </div>

                      <div class="form-group">
                        <label for="corporationZip">Zip Code</label>
                        <input type="text" value="{{ old('corporation_zip', $report->corporation_zip ?? '') }}" class="form-control" name="corporation_zip" id="corporationZip" placeholder="Enter zip code">
                      </div>

                      <div class="form-group">
                        <label for="corporationCity">City</label>
                        <input type="text" value="{{ old('corporation_city', $report->corporation_city ?? '') }}" class="form-control" name="corporation_city" id="corporationCity" placeholder="Enter city">
                      </div>
                    </div>

                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="fein">FEIN</label>
                        <input type="text" value="{{ old('fein', $report->fein ?? '') }}" class="form-control" name="fein" id="fein" placeholder="Enter FEIN">
                      </div>

                      <div class="form-group">
                        <label for="corporationState">State</label>
                        <input type="text" value="{{ old('corporation_state', $report->corporation_state ?? '') }}" class="form-control" name="corporation_state" id="corporationState" placeholder="Enter state">
                      </div>
                    </div>

                    <div class="col-md-12">
                      <div class="form-group">
                        <label for="corporationAddress">Address</label>
                        <input type="text" value="{{ old('corporation_address', $report->corporation_address ?? '') }}" class="form-control" name="corporation_address" id="corporationAddress" placeholder="Enter address">
                      </div>
                    </div>

                  </div>


                  <!-- Contact Information -->
                  <h4>Contact Information</h4>
                  <div class="row">
                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="firstName">First Name</label>
                        <input type="text" value="{{ old('first_name', $report->first_name ?? '') }}" class="form-control" name="first_name" id="firstName" placeholder="Enter first name">
                        @error('first_name')
                        <span class="text-danger">{{ $message }}</span>
                        @enderror
                      </div>

                      <div class="form-group">
                        <label for="contactFax">Fax</label>
                        <input type="tel" value="{{ old('contact_fax', $report->contact_fax ?? '') }}" class="form-control" name="contact_fax" id="contactFax" placeholder="(123) 456-7890">
                      </div>

                    </div>

                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="lastName">Last Name</label>
                        <input type="text" value="{{ old('last_name', $report->last_name ?? '') }}" class="form-control" name="last_name" id="lastName" placeholder="Enter last name">
                        @error('last_name')
                        <span class="text-danger">{{ $message }}</span>
                        @enderror
                      </div>

                      <div class="form-group">
                        <label for="contactCityStateZip">City, State, Zip</label>
                        <input type="text" value="{{ old('contact_city_state_zip', $report->contact_city_state_zip ?? '') }}" class="form-control" name="contact_city_state_zip" id="contactCityStateZip" placeholder="Enter city, state, zip">
                      </div>

                    </div>

                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="contactPhone">Phone</label>
                        <input type="tel" value="{{ old('contact_phone', $report->contact_phone ?? '') }}" class="form-control" name="contact_phone" id="contactPhone" placeholder="(123) 456-7890">
                        @error('contact_phone')
                        <span class="text-danger">{{ $message }}</span>
                        @enderror
                      </div>
                    </div>

                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="contactEmail">Email</label>
                        <input type="email" value="{{ old('contact_email', $report->contact_email ?? '') }}" class="form-control" name="contact_email" id="contactEmail" placeholder="Enter email">
                        @error('contact_email')
                        <span class="text-danger">{{ $message }}</span>
                        @enderror
                      </div>

                    </div>
                    <div class="col-md-12">
                      <div class="form-group">
                        <label for="contactAddress">Address</label>
                        <input type="text" value="{{ old('contact_address', $report->contact_address ?? '') }}" class="form-control" name="contact_address" id="contactAddress" placeholder="Enter address">
                      </div>
                    </div>
                  </div>


                  <!-- Authorization Section -->
                  <h4>Authorization</h4>
                  <div class="row">
                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="corporateOfficerName">Corporate Officer Name</label>
                        <input type="text" value="{{ old('corporate_officer_name', $report->corporate_officer_name ?? '') }}" class="form-control" name="corporate_officer_name" id="corporateOfficerName" placeholder="Enter corporate officer name">
                      </div>
                      <div class="form-group">
                        <label for="authorizationDate">Date</label>
                        <input type="date" value="{{ old('authorization_date', $report->authorization_date ?? '') }}" class="form-control" name="authorization_date" id="authorizationDate">
                      </div>
                    </div>

                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="corporateOfficerTitle">Title</label>
                        <input type="text" value="{{ old('corporate_officer_title', $report->corporate_officer_title ?? '') }}" class="form-control" name="corporate_officer_title" id="corporateOfficerTitle" placeholder="Enter title">
                      </div>
                      <div class="form-group">
                        <label for="corporateOfficerSignature">Corporate Officer Signature</label>
                        <input type="text" value="{{ old('corporate_officer_signature', $report->corporate_officer_signature ?? '') }}" class="form-control" name="corporate_officer_signature" id="corporateOfficerSignature" placeholder="Enter signature">
                      </div>
                    </div>

                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="dissolutionFee">Dissolution Fee</label>
                        <input type="text" value="{{ old('dissolution_fee', $report->dissolution_fee ?? '') }}" class="form-control" name="dissolution_fee" id="dissolutionFee" placeholder="Enter dissolution fee">
                      </div>

                    </div>


                  </div>


                  <!-- Credit Card Authorization -->
                  <h4>Credit Card Authorization</h4>
                  <div class="row">
                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="cardType">Card Type</label>
                        <select class="form-control" id="cardType" name="card_type">
                          <option value="Visa" {{ old('card_type', $report->card_type ?? '') == 'Visa' ? 'selected' : '' }}>Visa</option>
                          <option value="MasterCard" {{ old('card_type', $report->card_type ?? '') == 'MasterCard' ? 'selected' : '' }}>MasterCard</option>
                          <option value="American Express" {{ old('card_type', $report->card_type ?? '') == 'American Express' ? 'selected' : '' }}>American Express</option>
                          <option value="Discover" {{ old('card_type', $report->card_type ?? '') == 'Discover' ? 'selected' : '' }}>Discover</option>
                        </select>
                      </div>

                      <div class="form-group">
                        <label for="csvCode">Security (CSV) Code</label>
                        <input type="text" value="{{ old('csv_code', $report->csv_code ?? '') }}" class="form-control" name="csv_code" id="csvCode" placeholder="Enter CSV code">
                      </div>
                    </div>

                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="cardName">Name on the Credit Card</label>
                        <input type="text" value="{{ old('card_name', $report->card_name ?? '') }}" class="form-control" name="card_name" id="cardName" placeholder="Enter name on the card">
                      </div>

                      <div class="form-group">
                        <label for="cardNumber">Credit Card Number</label>
                        <input type="text" value="{{ old('card_number', $report->card_number ?? '') }}" class="form-control" name="card_number" id="cardNumber" placeholder="Enter credit card number">
                      </div>
                    </div>

                    <div class="col-md-6 col-print-6">


                      <div class="form-group">
                        <label for="billingCityStateZip">City, State, Zip</label>
                        <input type="text" value="{{ old('billing_city_state_zip', $report->billing_city_state_zip ?? '') }}" class="form-control" name="billing_city_state_zip" id="billingCityStateZip" placeholder="Enter city, state, zip">
                      </div>
                    </div>

                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="cardExpiration">Expiration Date</label>
                        <input type="month" value="{{ old('card_expiration', $report->card_expiration ?? '') }}" class="form-control" name="card_expiration" id="cardExpiration">
                      </div>
                    </div>

                    <div class="col-md-12">
                      <div class="form-group">
                        <label for="billingAddress">Billing Address</label>
                        <input type="text" value="{{ old('billing_address', $report->billing_address ?? '') }}" class="form-control" name="billing_address" id="billingAddress" placeholder="Enter billing address">
                      </div>
                    </div>
                  </div>

                </div>

                <div class="card-footer">
                  <button type="submit" class="btn btn-primary" id="submitButton">Submit</button>
                </div>
              </form>

          </div>
        </div>
      </div>
    </div>
  </section>
</div>
@include('dashboard.layouts.footer')

<script>
  function formatUSPhone(input) {
    
    let value = input.value.replace(/\D/g, ''); // remove non-digits
    if (value.length > 3 && value.length <= 6) {
      input.value = `(${value.slice(0, 3)}) ${value.slice(3)}`;
    } else if (value.length > 6) {
      input.value = `(${value.slice(0, 3)}) ${value.slice(3, 6)}-${value.slice(6, 10)}`;
    } else {
      input.value = value;
    }
  }
document.addEventListener("DOMContentLoaded", function() {
  document.getElementById('contactFax').addEventListener('input', function() {
    formatUSPhone(this);
  });
   document.getElementById('contactPhone').addEventListener('input', function() {
    formatUSPhone(this);
  });
 });
  
</script>
<script>
  $(function() {
    bsCustomFileInput.init();
  });
</script>
<script>
  function disableButton() {
    let btn = document.getElementById('submitButton');
    btn.disabled = true;
    btn.innerText = 'Submitting...'; // Change button text

    // Allow form submission
    return true;
  }
</script>
</body>

</html>