@include('dashboard.layouts.header')

<div class="content-wrapper">
  <section class="content-header">
    <div class="container-fluid">
      <div class="row mb-2">
        <div class="col-sm-6">
          <h1>SANP Food Stamp License</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">SANP Food Stamp License</li>
          </ol>
        </div>
      </div>
    </div>
  </section>

  <section class="content">
    <div class="container-fluid">
      <div class="row">
        <div class="col-md-12">
          <div class="card card-primary">
            <div class="card-header">
              <h3 class="card-title">SANP Food Stamp License Form</h3>
            </div>
            </br>

            @if (session('success'))
            <div class="alert alert-success">{{ session('success') }}</div>
            @endif

            @if(isset($report))
            <form action="{{ route('snap-food-stamp-license-submit-form.update', $report->id) }}" method="POST" onsubmit="disableButton()">
              @csrf
              @method('PUT')
              @else
              <form action="{{ route('snap-food-stamp-license-submit-form') }}" method="POST" onsubmit="disableButton()">
                @csrf
                @endif

                <div class="card-body">

                  <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="fax">Fax</label>
                        <input type="tel" value="{{ old('fax', $report->fax ?? '') }}" class="form-control" name="fax" id="fax" 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="suite">Suite/Apt</label>
                        <input type="text" value="{{ old('suite', $report->suite ?? '') }}" class="form-control" name="suite" id="suite" placeholder="Enter suite/apt">
                      </div>
                    </div>
                  </div>
                  <div class="row">
                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="phone">Phone</label>
                        <input type="tel" value="{{ old('phone', $report->phone ?? '') }}" class="form-control" name="phone" id="phone" placeholder="(123) 456-7890">
                        @error('phone')
                        <span class="text-danger">{{ $message }}</span>
                        @enderror
                      </div>
                      <div class="form-group">
                        <label for="cityStateZip">City, State, Zip</label>
                        <input type="text" value="{{ old('city_state_zip', $report->city_state_zip ?? '') }}" class="form-control" name="city_state_zip" id="cityStateZip" placeholder="Enter city, state, zip">
                      </div>
                    </div>
                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="email">Email address</label>
                        <input type="email" value="{{ old('email', $report->email ?? '') }}" class="form-control" name="email" id="email" placeholder="Enter email">
                        @error('email')
                        <span class="text-danger">{{ $message }}</span>
                        @enderror
                      </div>
                    </div>

                  </div>
                  <div class="row">
                    <div class="col-md-12">
                      <div class="form-group">
                        <label for="address">Address</label>
                        <input type="text" value="{{ old('address', $report->address ?? '') }}" class="form-control" name="address" id="address" placeholder="Enter address">
                      </div>
                    </div>
                  </div>
                  <hr>
                  <!-- Company Info -->
                  <h4>Company Information</h4>
                  <div class="row">
                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="entityName">Company Name</label>
                        <input type="text" value="{{ old('entity_name', $report->entity_name ?? '') }}" class="form-control" name="entity_name" id="entityName" placeholder="Enter entity name">
                      </div>
                      <div class="form-group">
                        <label for="stateFormation">State of Formation</label>
                        <input type="text" value="{{ old('state_formation', $report->state_formation ?? '') }}" class="form-control" name="state_formation" id="stateFormation" placeholder="Enter state">
                      </div>
                      <div class="form-group">
                        <label for="suite">Yearly Sales</label>
                        <input type="number" value="{{ old('yearly_sales', $report->yearly_sales ?? '') }}" class="form-control" name="yearly_sales" id="yearly_sales">
                      </div>
                      <!-- <div class="form-group">
                        <label>Selected Tax Year</label>
                        <input type="text" class="form-control" name="selected_tax_year" value="{{ old('selected_tax_year', $report->selected_tax_year ?? '') }}" placeholder="Tax Year">
                      </div> -->
                      <div class="form-group">
                        <label>Employer ID Number</label>
                        <input type="text" class="form-control" name="ein_number" value="{{ old('ein_number', $report->ein_number ?? '') }}" placeholder="Employer ID Number">
                      </div>
                      <div class="form-group">
                        <label for="hours_of_operation">Hours of Operation
                        </label>
                        <input type="date" value="{{ old('hours_of_operation', $report->hours_of_operation ?? '') }}" class="form-control" name="hours_of_operation" id="hours_of_operation">
                      </div>
                    </div>
                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="entityType">Type of Entity</label>
                        <select class="form-control" name="entity_type" id="entityType">
                          <option value="Corporation" {{ old('entity_type', $report->entity_type ?? '') == 'Corporation' ? 'selected' : '' }}>Corporation</option>
                          <option value="S Corporation" {{ old('entity_type', $report->entity_type ?? '') == 'S Corporation' ? 'selected' : '' }}>S Corporation</option>
                          <option value="Partnership" {{ old('entity_type', $report->entity_type ?? '') == 'Partnership' ? 'selected' : '' }}>Partnership</option>
                          <option value="Single Member LLC" {{ old('entity_type', $report->entity_type ?? '') == 'Single Member LLC' ? 'selected' : '' }}>Single Member LLC</option>
                          <option value="Multi Member LLC" {{ old('entity_type', $report->entity_type ?? '') == 'Multi Member LLC' ? 'selected' : '' }}>Multi Member LLC</option>
                          <option value="Sole Proprietor" {{ old('entity_type', $report->entity_type ?? '') == 'Sole Proprietor' ? 'selected' : '' }}>Sole Proprietor</option>
                        </select>
                      </div>

                      <div class="form-group">
                        <label for="dateFormation">Date of Formation (mm/dd/yyyy)</label>
                        <input type="date" value="{{ old('date_formation', $report->date_formation ?? '') }}" class="form-control" name="date_formation" id="dateFormation">
                      </div>

                      <div class="form-group">
                        <label for="ciCityStateZip">City, State, Zip</label>
                        <input type="text" value="{{ old('ci_city_state_zip', $report->ci_city_state_zip ?? '') }}" class="form-control" name="ci_city_state_zip" id="ciCityStateZip" placeholder="Enter City, State, Zip">
                      </div>
                      <div class="form-group">
                        <label for="ci_country">Country</label>
                        <input type="text" value="{{ old('ci_country', $report->ci_country ?? '') }}" class="form-control" name="ci_country" id="ci_country" placeholder="Enter Country">
                      </div>


                    </div>
                  </div>
                  <div class="row">
                    <div class="col-md-12">
                      <div class="form-group">
                        <label for="suite">Address</label>
                        <input type="text" value="{{ old('ci_address', $report->ci_address ?? '') }}" class="form-control" name="ci_address" id="ci_address" placeholder="Address">
                      </div>
                    </div>
                  </div>
                  <div class="row">
                    <div class="col-md-12">
                      <div class="form-group">
                        <label for="list_product_sold">List of all Product sold in Store and Volume</label>
                        <textarea class="form-control" name="list_product_sold" id="list_product_sold" rows="3">{{ old('list_product_sold', $report->list_product_sold ?? '') }}</textarea>
                      </div>

                    </div>
                  </div>


                  <hr>

                  <!-- Shareholder 1 -->
                  <h4>Shareholder Information</h4></br>
                  <h4>Shareholder 1</h4>
                  <div class="row">
                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="shareholder1Name">Full Name</label>
                        <input type="text" value="{{ old('shareholder1_name', $report->shareholder1_name ?? '') }}" class="form-control" name="shareholder1_name" id="shareholder1Name" placeholder="Enter Full Name">
                      </div>

                      <div class="form-group">
                        <label for="shareholder1Ownership">Percentage of Ownership</label>
                        <input type="text" value="{{ old('shareholder1_ownership', $report->shareholder1_ownership ?? '') }}" class="form-control" name="shareholder1_ownership" id="shareholder1Ownership" placeholder="Enter Ownership Percentage">
                      </div>

                      <div class="form-group">
                        <label for="shareholder1CityStateZip">City, State, Zip</label>
                        <input type="text" value="{{ old('shareholder1_city_state_zip', $report->shareholder1_city_state_zip ?? '') }}" class="form-control" name="shareholder1_city_state_zip" id="shareholder1CityStateZip" placeholder="Enter City, State, Zip">
                      </div>



                    </div>

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

                      <div class="form-group">
                        <label for="shareholder1SSN">Social Security Number</label>
                        <input type="text" value="{{ old('shareholder1_ssn', $report->shareholder1_ssn ?? '') }}" class="form-control" name="shareholder1_ssn" id="shareholder1SSN" placeholder="999-99-9999">
                      </div>

                      <div class="form-group">
                        <label for="shareholder1Phone">Phone</label>
                        <input type="tel" value="{{ old('shareholder1_phone', $report->shareholder1_phone ?? '') }}" class="form-control" name="shareholder1_phone" id="shareholder1Phone" placeholder="(123) 456-7890">
                      </div>

                      <div class="form-group">
                        <label for="shareholder1Fax">Fax</label>
                        <input type="tel" value="{{ old('shareholder1_fax', $report->shareholder1_fax ?? '') }}" class="form-control" name="shareholder1_fax" id="shareholder1Fax" placeholder="(123) 456-7890">
                      </div>
                    </div>

                  </div>
                  <div class="row">
                    <div class="col-md-12">
                      <div class="form-group">
                        <label for="shareholder1Address">Residence Address</label>
                        <input type="text" value="{{ old('shareholder1_address', $report->shareholder1_address ?? '') }}" class="form-control" name="shareholder1_address" id="shareholder1Address" placeholder="Enter Address">
                      </div>
                    </div>
                  </div>
                  <!-- Shareholder 2 -->
                  <h4>Shareholder 2</h4>
                  <div class="row">
                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="shareholder2Name">Full Name</label>
                        <input type="text" value="{{ old('shareholder2_name', $report->shareholder2_name ?? '') }}" class="form-control" name="shareholder2_name" id="shareholder2Name" placeholder="Enter Full Name">
                      </div>
                      <div class="form-group">
                        <label for="shareholder2Ownership">Percentage of Ownership</label>
                        <input type="text" value="{{ old('shareholder2_ownership', $report->shareholder2_ownership ?? '') }}" class="form-control" name="shareholder2_ownership" id="shareholder2Ownership" placeholder="Enter Ownership Percentage">
                      </div>
                      <div class="form-group">
                        <label for="shareholder2CityStateZip">City, State, Zip</label>
                        <input type="text" value="{{ old('shareholder2_city_state_zip', $report->shareholder2_city_state_zip ?? '') }}" class="form-control" name="shareholder2_city_state_zip" id="shareholder2CityStateZip" placeholder="Enter City, State, Zip">
                      </div>
                    </div>

                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="shareholder2SSN">Social Security Number</label>
                        <input type="text" value="{{ old('shareholder2_ssn', $report->shareholder2_ssn ?? '') }}" class="form-control" name="shareholder2_ssn" id="shareholder2SSN" placeholder="999-99-9999">
                      </div>

                      <div class="form-group">
                        <label for="shareholder2Phone">Phone</label>
                        <input type="tel" value="{{ old('shareholder2_phone', $report->shareholder2_phone ?? '') }}" class="form-control" name="shareholder2_phone" id="shareholder2Phone" placeholder="(123) 456-7890">
                      </div>

                      <div class="form-group">
                        <label for="shareholder2Fax">Fax</label>
                        <input type="tel" value="{{ old('shareholder2_fax', $report->shareholder2_fax ?? '') }}" class="form-control" name="shareholder2_fax" id="shareholder2Fax" placeholder="(123) 456-7890">
                      </div>
                    </div>
                  </div>

                  <div class="row">
                    <div class="col-md-12">

                      <div class="form-group">
                        <label for="shareholder2Address">Residence Address</label>
                        <input type="text" value="{{ old('shareholder2_address', $report->shareholder2_address ?? '') }}" class="form-control" name="shareholder2_address" id="shareholder2Address" placeholder="Enter Address">
                      </div>
                    </div>
                  </div>


                  <hr>
                  <div class="form-group">
                    <p>
                      I authorize ITAXEXPERTS.COM to Apply for Retail Cigarette License and willing to pay $
                      <input type="number" value="{{ old('fee_amount', $report->fee_amount ?? '') }}" class="form-control d-inline-block w-auto" name="fee_amount" placeholder="Enter amount">
                      (exclusive of State and county Fee).
                      </br>
                      ^Please fill in Fee Amount as Mentioned in Fee Schedule. Or Fee Discussed with Accountant.

                    </p>
                  </div>

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

                      <div class="form-group">
                        <label>Name</label>
                        <input type="text" class="form-control" name="signature_name"
                          value="{{ old('signature_name', $report->signature_name ?? '') }}" placeholder="Signature Name">

                      </div>
                      <div class="form-group">
                        <label>Date</label>
                        <input type="date" class="form-control" name="signature_date"
                          value="{{ old('signature_date', $report->signature_date ?? '') }}" placeholder="Signature Date">
                      </div>
                    </div>

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

                  </div>
                  <hr>
                  <!-- Credit Card -->
                  <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="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 class="form-group">
                        <label for="expiryDate">Expiration Date</label>
                        <input type="month" value="{{ old('card_expiration', $report->card_expiration ?? '') }}" class="form-control" name="card_expiration" id="expiryDate">
                      </div>

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

                    </div>


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

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


                      <!-- Signature -->
                      <div class="form-group">
                        <label for="signature">Signature of Card Holder</label>
                        <input type="text" value="{{ old('card_signature', $report->card_signature ?? '') }}" class="form-control" name="card_signature" id="signature" placeholder="Enter Signature">
                      </div>

                    </div>
                  </div>

                  <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>
                  <!-- Notes Section -->
                  <div class="form-group">
                    <label for="notes">Notes</label>
                    <textarea class="form-control" name="notes" id="notes" rows="3" placeholder="Enter any notes">{{ old('notes', $report->notes ?? '') }}</textarea>
                  </div>

                </div>

                <div class="card-footer">
                  <button type="submit" id="submitButton" class="btn btn-primary">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('phone').addEventListener('input', function() {
      formatUSPhone(this);
    });
    document.getElementById('fax').addEventListener('input', function() {
      formatUSPhone(this);
    });
    document.getElementById('shareholder1Phone').addEventListener('input', function() {
      formatUSPhone(this);
    });
    document.getElementById('shareholder1Fax').addEventListener('input', function() {
      formatUSPhone(this);
    });
    document.getElementById('shareholder2Phone').addEventListener('input', function() {
      formatUSPhone(this);
    });
    document.getElementById('shareholder2Fax').addEventListener('input', function() {
      formatUSPhone(this);
    });
  });

  function formatUSSSN(input) {
    let value = input.value.replace(/\D/g, ''); // remove all non-digits

    if (value.length > 5) {
      // 123-45-6789
      input.value = `${value.slice(0, 3)}-${value.slice(3, 5)}-${value.slice(5, 9)}`;
    } else if (value.length > 3) {
      // 123-45
      input.value = `${value.slice(0, 3)}-${value.slice(3, 5)}`;
    } else {
      // 123
      input.value = value;
    }
  }
  document.addEventListener("DOMContentLoaded", function() {
    document.getElementById('shareholder1SSN').addEventListener('input', function() {
      formatUSSSN(this);
    });
    document.getElementById('shareholder2SSN').addEventListener('input', function() {
      formatUSSSN(this);
    });
    document.getElementById('ci_ssn').addEventListener('input', function() {
      formatUSSSN(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>