| Server IP : 10.200.247.200 / Your IP : 216.73.217.19 Web Server : Apache System : Linux synergy-usa-sites 6.8.0-138-generic #138-Ubuntu SMP PREEMPT_DYNAMIC Fri Jul 31 22:41:49 UTC 2026 x86_64 User : jeremy ( 1001) PHP Version : 8.4.25 Disable Function : NONE MySQL : OFF | cURL : ON | WGET : ON | Perl : ON | Python : OFF | Sudo : ON | Pkexec : OFF Directory : /var/www/loan_sites/fasttracktitleloans.com/ |
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<?php
header("Location: /v3/");
exit(0);
include 'includes/autoload.php';
include_once($_SERVER['DOCUMENT_ROOT'].'/php/mailgun.php');
if($_GET['submitted']==1) {
$_SESSION = array();
$page = 'apply';
$form = 'none';
$pageHtml = '<h1>YOUR APPLICATION HAS BEEN RECEIVED, WE WILL BE IN CONTACT WITH YOU SOON.</h1>';
include 'includes/layout.php';
die();
}
include_once($_SERVER['DOCUMENT_ROOT'].'/php/form_tracking.php');
ob_start();
include_once('php/db_config_lc_user.php');
$db = connect_lc2user_new('title_loans');
if(!empty($_POST)) {
$_SESSION['passed_recaptcha'] = '1';
$recaptcha_passed = true;
/*if(isset($_POST['g-recaptcha-response'])) {
if(!function_exists('PostFields')) {
function PostFields($url,$fields)
{
$fields = http_build_query($fields);
$ch = curl_init();
curl_setopt($ch, CURLOPT_RETURNTRANSFER, 1);
curl_setopt($ch, CURLOPT_FOLLOWLOCATION, 1);
curl_setopt($ch, CURLOPT_REFERER, $_SERVER["HTTP_HOST"] . $_SERVER['REQUEST_URI']);
curl_setopt($ch, CURLOPT_URL, $url);
curl_setopt($ch, CURLOPT_POST, 1);
curl_setopt($ch, CURLOPT_POSTFIELDS, $fields);
curl_setopt($ch, CURLOPT_SSL_VERIFYPEER, FALSE);
curl_setopt($ch, CURLOPT_USERAGENT, "LCAPI cUrl Agent");
curl_setopt($ch, CURLOPT_VERBOSE, true);
ob_start();
$data = curl_exec ($ch);
ob_end_clean();
curl_close ($ch);
return $data;
}
}
$postfields = array();
$postfields['secret'] = '6LfvbPgSAAAAAHX1zdxh45DJ6FV-tB72XA2XRd3E';
$postfields['response'] = $_POST['g-recaptcha-response'];
$postfields['remoteip'] = $_SERVER['REMOTE_ADDR'];
$recaptcha_response = PostFields('https://www.google.com/recaptcha/api/siteverify',$postfields);
$json_response = json_decode($recaptcha_response);
$recaptcha_passed = false;
if($json_response->success) {
$recaptcha_passed = true;
}
if(!$recaptcha_passed) {
$querystring = '';
foreach($_POST as $k=>$v) {
$querystring .= ($querystring=='') ? '' : '&';
$querystring .= urlencode($k).'='.urlencode($v);
}
$querystring .= '&invalid_captcha=1';
header("Location: index.php?".$querystring);
} else {
$_SESSION['passed_recaptcha'] = '1';
}
}*/
if((empty($_POST['cell_phone']) && empty($_POST['home_phone'])) || preg_match('/[0-9]+/',$_POST['first_name']) || !$recaptcha_passed) {
header("Location: apply.php");
exit(0);
}
if($_POST['form_type']=='basic_application' && !empty($_POST['cell_phone']) && $recaptcha_passed) {
$_POST['advertising_type'] = $_POST['hear_about'];
foreach($_POST as $k=>$v) {
$_SESSION['application'][$k] = $v;
}
/*$res = $db->get_results("SELECT * FROM full_application WHERE id='".$db->clean($_SESSION['application']['application_id'])."'");
if(empty($res)) {
$db->query("INSERT INTO full_application (company_id,ts,ip_address)
VALUES (
'2',
NOW(),
'".$db->clean($_SERVER['REMOTE_ADDR'])."'
)");
$_SESSION['application']['application_id'] = $db->last_insert_id();
}*/
$db->query("INSERT INTO basic_application (company_id,type_of_loan,first_name,last_name,email,home_phone,cell_phone,vehicle_make,vehicle_model,vehicle_year,vehicle_trim,mileage,best_time_to_contact,ts,how_much_do_you_need)
VALUES (
'2',
'".$db->clean($_POST['type_of_loan'])."',
'".$db->clean($_POST['first_name'])."',
'".$db->clean($_POST['last_name'])."',
'".$db->clean($_POST['email'])."',
'".$db->clean(preg_replace('/[^0-9]/','',$_POST['home_phone']))."',
'".$db->clean(preg_replace('/[^0-9]/','',$_POST['cell_phone']))."',
'".$db->clean($_POST['vehicle_make'])."',
'".$db->clean($_POST['vehicle_model'])."',
'".$db->clean($_POST['vehicle_year'])."',
'".$db->clean($_POST['vehicle_trim'])."',
'".$db->clean($_POST['mileage'])."',
'".$db->clean($_POST['best_time_to_contact'])."',
'".date('Y-m-d H:i:s')."',
'".$db->clean($_POST['how_much_do_you_need'])."'
)");
/*$res = $db->get_results("SELECT * FROM customers WHERE email='".$db->clean($_POST['email'])."' AND email<>'' AND company_id=2 ORDER BY ts DESC LIMIT 1");
if(empty($res)) {
$db->query("INSERT INTO customers (company_id,first_name,last_name,email,home_phone,cell_phone,ts)
VALUES (
'2',
'".$db->clean($_POST['first_name'])."',
'".$db->clean($_POST['last_name'])."',
'".$db->clean($_POST['email'])."',
'".$db->clean(preg_replace('/[^0-9]/','',$_POST['home_phone']))."',
'".$db->clean(preg_replace('/[^0-9]/','',$_POST['cell_phone']))."',
'".date('Y-m-d H:i:s')."'
)");
$_SESSION['application']['customer_id'] = $db->last_insert_id();
$db->query("UPDATE full_application SET customer_id='".$db->clean($_SESSION['application']['customer_id'])."' WHERE id='".$db->clean($_SESSION['application']['application_id'])."'");
}*/
$subject = 'Applicant for Fast Track Title Loans: '.$_POST['first_name']." ".$_POST['last_name']." | ".date('F j, Y g:i a');
$body = '
<html>
<head>
<title>Applicant for Fast Track Title Loans: '.$_POST['first_name']." ".$_POST['last_name'].' | '.date('F j, Y').'</title>
</head>
<body>
<p>The home page application form has been filled out by:</p>
<table border=\'0px\' cellpadding=\'12px\' width=\'600px\' style=\'border:1px solid #000; border-radius:5px; background-color:#c9d3b1;\'>
<tr style=\'background-color:#4a5334; color:#FFF;\'>
<th style=\'border-radius:3px;\'>
Type of Loan
</th>
<th style=\'border-radius:3px;\'>
First Name
</th>
<th style=\'border-radius:3px;\'>
Last Name
</th>
<th style=\'border-radius:3px;\'>
Email
</th>
<th style=\'border-radius:3px;\'>
Home Phone
</th>
<th style=\'border-radius:3px;\'>
Mobile Phone
</th>
</tr>
<tr>
<td>
'.$_POST['type_of_loan'].'
</td>
<td>
'.$_POST['first_name'].'
</td>
<td>
'.$_POST['last_name'].'
</td>
<td>
'.$_POST['email'].'
</td>
<td>
'.$_POST['home_phone'].'
</td>
<td>
'.$_POST['cell_phone'].'
</td>
</tr>
<tr style=\'background-color:#4a5334; color:#FFF;\'>
<th style=\'border-radius:3px;\'>
Vehicle Year
</th>
<th style=\'border-radius:3px;\'>
Vehicle Make
</th>
<th style=\'border-radius:3px;\'>
Vehicle Model
</th>
<th colspan=\'3\' style=\'border-radius:3px;\'>
Vehicle Mileage
</th>
</tr>
<tr>
<td>
'.$_POST['vehicle_year'].'
</td>
<td>
'.$_POST['vehicle_make'].'
</td>
<td>
'.$_POST['vehicle_model'].'
</td>
<td colspan=\'2\'>
'.$_POST['mileage'].'
</td>
</tr>
<tr style=\'background-color:#4a5334; color:#FFF;\'>
<th colspan=\'4\' style=\'border-radius:3px;\'>
How did you hear about us?
</th>
<th colspan=\'2\' style=\'border-radius:3px;\'>
How much do you need?
</th>
</tr>
<tr>
<td colspan=\'4\' align=\'center\'>
'.$_POST['hear_about'].'
</td>
<td colspan=\'2\' align\'center\'>
'.$_POST['how_much_do_you_need'].'
</td>
</tr>
</table>
</body>
</html>';
require_once("php/Mail.php");
if($_POST['email']=='jeremy@synergytpsreports.com') {
} else {
/*$host = "ssl://smtp.gmail.com";
$port = "465";
$username = "frontoffice@personalgranthelp.com"; //<> give errors
$password = "Syn3rgy2016";
$to = "support@fasttracktitleloans.com, hanskirchhausen@gmail.com, heinz57@gmail.com, admin@fasttracktitleloans.com, kammeeplant@gmail.com";
//$to = 'jeremy@synergytpsreports.com';
$from = ucwords(strtolower($_POST['first_name'])).ucwords(strtolower($_POST['last_name']))."@surfcrm.com";
$headers = array ('From' => $from,
//'Reply-to' => $from,
'To' => $to,
'Subject' => $subject,
'MIME-Version' => "1.0",
'Content-Type' => "text/html; charset=iso-8859-1");
$smtp = Mail::factory('smtp',
array ('host' => $host,
'port' => $port,
'auth' => true,
'username' => $username,
'password' => $password));
$mail = $smtp->send($to, $headers, $body);
if (PEAR::isError($mail)) {
$smtp = Mail::factory('mail');
$mail = $smtp->send($to, $headers, $body);
mail('jeremy@synergytpsreports.com','fasttrack email disabled','The fasttrack email account is disabled again',"From:noreply@surfcrm.com\r\n");
}*/
//mailgun_send_message('support@fasttracktitleloans.com','new_lead@fasttrackloancenter.com',$subject,$body,1,'FastTrack Basic Application','heinz57@gmail.com','','title_loans','0');
}
//send text to Heinz, Hans, Kammee, Holger, Stephanie, Veronica
$from = $_POST['first_name'].'_'.$_POST['last_name']."@surfcrm.com";
$to = "4352295757@mms.att.net,4352290059@mms.att.net,4352295759@mms.att.net";
//$to = "4358623428@msg.fi.google.com";
$subject = 'Fast Track - '.$_POST['first_name'].' '.$_POST['last_name'];
$body = "{$_POST['type_of_loan']} loan, {$_POST['first_name']} {$_POST['last_name']}, Phone: {$_POST['home_phone']}, {$_POST['cell_phone']}, Email: {$_POST['email']}";
//mail($to,$subject,$body,"From:{$from}\r\n",'-f'.$from);
/*$to = "4358627874@vtext.com";
mail($to,$subject,$body,"From:{$from}\r\n",'-f'.$from);
$to = "4358628741@mms.att.net";
mail($to,$subject,$body,"From:{$from}\r\n",'-f'.$from);
$to = "4352295518@messaging.sprintpcs.com";
mail($to,$subject,$body,"From:{$from}\r\n",'-f'.$from);*/
}
} elseif(!empty($_SESSION['application'])) {
foreach($_SESSION['application'] as $k=>$v) {
$_POST[$k] = $v;
}
} else {
$db->query("INSERT INTO full_application (company_id,ts,ip_address)
VALUES (
'2',
NOW(),
'".$db->clean($_SERVER['REMOTE_ADDR'])."'
)");
$_SESSION['application']['application_id'] = $db->last_insert_id();
$db->query("INSERT INTO customers (company_id,ts,ip_address)
VALUES (
'2',
'".date('Y-m-d H:i:s')."',
'".$db->clean($_SERVER['REMOTE_ADDR'])."'
)");
$_SESSION['application']['customer_id'] = $db->last_insert_id();
$db->query("UPDATE full_application SET customer_id='".$db->clean($_SESSION['application']['customer_id'])."' WHERE id='".$db->clean($_SESSION['application']['application_id'])."'");
}
$body_id = 'apply';
?>
<script src='https://www.google.com/recaptcha/api.js'></script>
<script type="text/javascript">
var checking_ssn = false;
function check_ssn(me) {
if($(me).val().length==11) {
if(!checking_ssn) {
checking_ssn = true;
var str = 'ssn='+encodeURIComponent($(me).val());
$.ajax
({
cache: false,
type: "POST",
data: str,
url: "/php/check_ssn.php",
success: function(msg)
{
if($('#ssn_error_area').length>0) {
$('#ssn_error_area').remove();
}
checking_ssn = false;
if(msg=='1') {
$(me).after('<div id="ssn_error_area" style="background:#993333;color:white;font-weight:bold;">This Social Security Number is already attached to an account. Please contact customer service.</div>');
}
}
});
}
} else {
if($('#ssn_error_area').length>0) {
$('#ssn_error_area').remove();
}
}
}
</script>
<div class="main container">
<div class="size">
<form method="post" id='apply-form' action="/application/in-out-loan-p1_v2.php" onsubmit="return check(this);">
<div class="mini_form" id="tell_us_about_yourself">
<h1>Tell us about yourself</h1>
<div class="form">
<div class='row'>
<div class='col-sm-12'>
<h4>What type of loan are you looking for?</h4>
</div>
<div class='col-sm-6 nopad'>
<div class="ui-form-element" style="width:auto;display:block;">
<label><input type="radio" name="type_of_loan" value="signature" onclick="update_loan_type(this);" /> Signature Loan</label>
<label><input type="radio" name="type_of_loan" value="title_loan" onclick="update_loan_type(this);" /> Title Loan</label>
<!-- <label><input type="radio" name="type_of_loan" value="payday" onclick="update_loan_type(this);" /> Payday Loan</label> -->
</div>
</div>
</div>
<div class="row extra_info signature payday">
<div class="col-sm-12">
<table style="border:none; border-collapse:separate; border-spacing:5px;">
<tr>
<td></td>
<td>Basic Requirements for Approval</td>
</tr>
<tr>
<td>1.</td>
<td>At least $500 of income every two weeks</td>
</tr>
<tr>
<td>2.</td>
<td>At least 6 months on your current job</td>
</tr>
<tr>
<td>3.</td>
<td>Active checking account</td>
</tr>
<tr>
<td>4.</td>
<td>Legal U.S. Citizenship</td>
</tr>
<tr>
<td>5.</td>
<td>Must be a Utah resident</td>
</tr>
<tr>
<td></td>
<td><i>*Please do not apply if you do not meet these basic requirements*</i></td>
</tr>
</table>
</div>
</div>
<div class='row'>
<div class='col-sm-12'>
<h4>How did you hear about us?*</h4>
</div>
<div class="col-sm-6 nopad">
<div class="ui-form-element" style="width:auto;display:block;">
<select class="form-control required" name="advertising_type" onchange="if($(this).val()=='Other' || $(this).val()=='Referral' || $(this).val()=='Friend' || $(this).val()=='Business Referral') { $(this).siblings().show(); } else { $(this).siblings().hide(); }">
<option value="">-</option>
<option value="Internet" <?= ($_POST['advertising_type']=='Internet') ? 'selected' : '';?>>Internet</option>
<option value="Facebook" <?= ($_POST['advertising_type']=='Facebook') ? 'selected' : '';?>>Facebook</option>
<option value="Radio" <?= ($_POST['advertising_type']=='Radio') ? 'selected' : '';?>>Radio</option>
<option value="Brochure" <?= ($_POST['advertising_type']=='Brochure') ? 'selected' : '';?>>Brochure</option>
<option value="Direct Mail" <?= ($_POST['advertising_type']=='Direct Mail') ? 'selected' : '';?>>Direct Mail</option>
<option value="Signs" <?= ($_POST['advertising_type']=='Signs') ? 'selected' : '';?>>Signs</option>
<option value="Referral" <?= ($_POST['advertising_type']=='Referral') ? 'selected' : '';?>>Referral</option>
<option value="Friend" <?= ($_POST['advertising_type']=='Friend') ? 'selected' : '';?>>Friend</option>
<option value="Other" <?= ($_POST['advertising_type']=='Other') ? 'selected' : '';?>>Other</option>
</select>
<input type="text" class="col-sm-6" style="display:none;" name="hear_other" id="hear_other" size="16" value="<?= $_POST['hear_other'];?>" />
</div>
</div>
</div>
<div class='row'>
<div class='col-md-6 col-sm-12'>
<div class='row'>
<div class="col-sm-4 nopad">
<strong>First Name*</strong><br />
<input type="text" name="first_name" class="form-control required" value="<?= $_POST['first_name'];?>" />
</div>
<div class="col-sm-4 nopad">
Middle Name<br />
<input type="text" name="middle_name" class="form-control" value="<?= $_POST['middle_name'];?>" />
</div>
<div class="col-sm-4 nopad">
<strong>Last Name*</strong><br />
<input type="text" name="last_name" class="form-control required" value="<?= $_POST['last_name'];?>" />
</div>
</div>
<div class='row'>
<div class="col-sm-12">
<strong>Street Address (and unit number)*</strong><br />
<input type="text" name="address" value="<?= $_POST['address'];?>" class="form-control required" />
</div>
<div class="col-sm-4">
City<br />
<input type="text" name="city" value="<?= $_POST['city'];?>" class="form-control required" />
</div>
<div class="nopad col-sm-4">
<div class="st">
<strong>State*</strong><br />
<select name="state" class="form-control required">
<option value="">state</option>
<?php
$states = array('AL'=>'Alabama','AK'=>'Alaska','AZ'=>'Arizona','AR'=>'Arkansas','CA'=>'California','CO'=>'Colorado','CT'=>'Connecticut','DE'=>'Delaware','DC'=>'District of Columbia','FL'=>'Florida','GA'=>'Georgia','HI'=>'Hawaii','ID'=>'Idaho','IL'=>'Illinois','IN'=>'Indiana','IA'=>'Iowa','KS'=>'Kansas','KY'=>'Kentucky','LA'=>'Louisiana','ME'=>'Maine','MD'=>'Maryland','MA'=>'Massachusetts','MI'=>'Michigan','MN'=>'Minnesota','MS'=>'Mississippi','MO'=>'Missouri','MT'=>'Montana','NE'=>'Nebraska','NV'=>'Nevada','NH'=>'New Hampshire','NJ'=>'New Jersey','NM'=>'New Mexico','NY'=>'New York','NC'=>'North Carolina','ND'=>'North Dakota','OH'=>'Ohio','OK'=>'Oklahoma','OR'=>'Oregon','PA'=>'Pennsylvania','RI'=>'Rhode Island','SC'=>'South Carolina','SD'=>'South Dakota','TN'=>'Tennessee','TX'=>'Texas','UT'=>'Utah','VT'=>'Vermont','VA'=>'Virginia','WA'=>'Washington','WV'=>'West Virginia','WI'=>'Wisconsin','WY'=>'Wyoming');
foreach($states as $k=>$v) {
?><option value="<?= $k;?>" <?= ($_POST['state']==$k) ? 'selected' : '';?>><?= $v;?></option><?php
}
?>
</select>
</div>
</div>
<div class="zp col-sm-4">
Zip<br />
<input type="tel" maxlength="5" name="zip" value="<?= $_POST['zip'];?>" class="form-control required" />
</div>
</div>
</div>
<div class='col-md-6 col-sm-12'>
<div class='row'>
<div class="col-sm-6">
<strong>Email*</strong><br />
<input type="text" name="email" value="<?= $_POST['email'];?>" class="form-control required" />
</div>
<div class="col-sm-6">
<strong>Social Security*</strong><br />
<input type="tel" maxlength="11" name="social_security" class="form-control ssn required" value="<?= $_POST['social_security'];?>" onkeyup="check_ssn(this);" />
</div>
<div class="col-sm-4">
Date of Birth<br />
<select class="form-control dm" name="dob_month">
<option>month</option>
<?php for($i=1;$i<=12;$i++) { ?>
<option value="<?= $i;?>" <?= ($_POST['dob_month']*1==$i) ? 'selected' : '';?>><?= date("F", mktime(0, 0, 0, $i, 10));?></option>
<?php } ?>
</select>
</div>
<div class='col-sm-4'>
<br>
<select class="form-control dd" name="dob_day">
<option>day</option>
<?php for($i=1;$i<=31;$i++) { ?>
<option value="<?= $i;?>" <?= ($_POST['dob_day']*1==$i) ? 'selected' : '';?>><?= $i;?></option>
<?php } ?>
</select>
</div>
<div class='col-sm-4'>
<br>
<select class="form-control dy" name="dob_year">
<option>year</option>
<?php for($i=(date('Y')*1-16); $i>= (date('Y')-100); $i--) { ?>
<option value="<?= $i;?>" <?= ($_POST['dob_year']*1==$i) ? 'selected' : '';?>><?= $i;?></option>
<?php } ?>
</select>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<strong>Home Phone*</strong><br />
<input type="tel" class="phone_number form-control required" name="home_phone" value="<?= $_POST['home_phone'];?>" />
</div>
<div class="col-sm-6">
<strong>Cell Phone*</strong><br />
<input type="tel" class="phone_number form-control required" name="cell_phone" value="<?= $_POST['cell_phone'];?>" />
</div>
<div class="col-sm-6">
Work Phone<br />
<input type="tel" class="phone_number form-control" name="work_phone" value="<?= $_POST['work_phone'];?>" />
</div>
<div class="col-sm-6">
Facebook Page<br />
<input type="text" class="form-control" name="facebook_page" value="<?= $_POST['facebook_page'];?>" />
</div>
</div>
</div>
</div>
<div class='row'>
<div class="col-sm-3">
Drivers License Number<br />
<input class='form-control' type="tel" maxlength="16" name="drivers_license_number" value="<?= $_POST['drivers_license_number'];?>" />
</div>
<div class="col-sm-3">
State Issued<br />
<select name="state_issued" class="form-control">
<option>state</option>
<?php
$states = array('AL'=>'Alabama','AK'=>'Alaska','AZ'=>'Arizona','AR'=>'Arkansas','CA'=>'California','CO'=>'Colorado','CT'=>'Connecticut','DE'=>'Delaware','DC'=>'District of Columbia','FL'=>'Florida','GA'=>'Georgia','HI'=>'Hawaii','ID'=>'Idaho','IL'=>'Illinois','IN'=>'Indiana','IA'=>'Iowa','KS'=>'Kansas','KY'=>'Kentucky','LA'=>'Louisiana','ME'=>'Maine','MD'=>'Maryland','MA'=>'Massachusetts','MI'=>'Michigan','MN'=>'Minnesota','MS'=>'Mississippi','MO'=>'Missouri','MT'=>'Montana','NE'=>'Nebraska','NV'=>'Nevada','NH'=>'New Hampshire','NJ'=>'New Jersey','NM'=>'New Mexico','NY'=>'New York','NC'=>'North Carolina','ND'=>'North Dakota','OH'=>'Ohio','OK'=>'Oklahoma','OR'=>'Oregon','PA'=>'Pennsylvania','RI'=>'Rhode Island','SC'=>'South Carolina','SD'=>'South Dakota','TN'=>'Tennessee','TX'=>'Texas','UT'=>'Utah','VT'=>'Vermont','VA'=>'Virginia','WA'=>'Washington','WV'=>'West Virginia','WI'=>'Wisconsin','WY'=>'Wyoming');
foreach($states as $k=>$v) {
?><option value="<?= $k;?>" <?= ($_POST['state']==$k) ? 'selected' : '';?>><?= $v;?></option><?php
}
?>
</select>
</div>
<div class="col-sm-2">
Date Expires<br />
<select class="dm form-control" name="date_expires_month">
<option>month</option>
<?php for($i=1;$i<=12;$i++) { ?>
<option value="<?= $i;?>" <?= ($_POST['date_expires_month']*1==$i) ? 'selected' : '';?>><?= date("F", mktime(0, 0, 0, $i, 10));?></option>
<?php } ?>
</select>
</div>
<div class='col-sm-2'>
<br>
<select class="dd form-control" name="date_expires_day">
<option>day</option>
<?php for($i=1;$i<=31;$i++) { ?>
<option value="<?= $i;?>" <?= ($_POST['date_expires_day']*1==$i) ? 'selected' : '';?>><?= $i;?></option>
<?php } ?>
</select>
</div>
<div class='col-sm-2'>
<br>
<select class="dy form-control" name="date_expires_year">
<option>year</option>
<?php for($i=(date('Y')*1); $i<= (date('Y')*1+5); $i++) { ?>
<option value="<?= $i;?>" <?= ($_POST['date_expires_year']*1==$i) ? 'selected' : '';?>><?= $i;?></option>
<?php } ?>
</select>
</div>
</div>
<div class='row'>
<div class='col-sm-6'>
<div class='row'>
<div class='col-sm-12'>
How long have you lived in your home?
</div>
<div class='col-sm-6'>
<input class='form-control' type="number" name="lived_in_home_1" value="<?= $_POST['lived_in_home_1'];?>" />
</div>
<div class='col-sm-6'>
<select class="form-control" name="lived_in_home_2">
<option></option>
<option value="Months" <?= ($_POST['lived_in_home_2']=='Months') ? 'selected' : '';?>>Months</option>
<option value="Years" <?= ($_POST['lived_in_home_2']=='Years') ? 'selected' : '';?>>Years</option>
</select>
</div>
</div>
</div>
<div class='col-sm-6'>
How much do you need?<br>
<input class='form-control' type="number" step="0.01" name="how_much_do_you_need" value="<?= $_POST['how_much_do_you_need'];?>" />
</div>
</div>
<div class='row'>
<div class='col-sm-3'>
Are you U.S. citizen?<br />
<label class="radio-inline" for="citizen_yes"><input type="radio" name="citizen" class="checkbox" id="citizen_yes" value="yes" <?= ($_POST['citizen']=='yes') ? 'checked' : '';?> /> Yes </label>
<label class="radio-inline" for="citizen_no"><input type="radio" name="citizen" class="checkbox" id="citizen_no" value="no" <?= ($_POST['citizen']=='no') ? 'checked' : '';?> /> No </label>
</div>
<div class='col-sm-9'>
<div class='row'>
<div class="col-sm-6">
Do you rent or own?<br />
<label class="radio-inline" for="rent_yes"><input type="radio" name="rent" class="checkbox" id="rent_yes" value="yes" <?= ($_POST['rent']=='yes') ? 'checked' : '';?> /> Rent </label>
<label class="radio-inline" for="rent_no"><input type="radio" name="rent" class="checkbox" id="rent_no" value="no" <?= ($_POST['rent']=='no') ? 'checked' : '';?> /> Own </label>
</div>
</div>
<div class='row'>
<div class='col-sm-6'>
Landlord's Name<br />
<input class='form-control' type="text" name="landlord_name" value="<?= $_POST['landlord_name'];?>" />
</div>
<div class='col-sm-6'>
Landlord's Phone<br />
<input class='form-control phone_number' type="tel" name="landlord_phone" value="<?= $_POST['landlord_phone'];?>" />
</div>
</div>
<div class='row'>
<div class="col-sm-6">
Name on Lease/Mortgage<br />
<input class='form-control' type="text" name="lease_owner" value="<?= $_POST['lease_owner'];?>" />
</div>
<div class="col-sm-6">
Monthly Lease/Mortgage Payment<br />
<input class='form-control' type="number" name="lease_amount" value="<?= $_POST['lease_amount'];?>" />
</div>
</div>
</div>
</div>
<div class="col-sm-12 javascript_save_button" style="display:none;">
<p>I acknowledgment that the information I have provided is true and correct information concerning income, obligations, and employment and that I do have the ability to repay this loan.</p>
<div class="g-recaptcha" data-sitekey="6LfvbPgSAAAAALLPfBbdoZC6zoI9bfMQGJScXV8w"></div>
<button class="submit" style="float:right;padding:0px 10px;" onclick="save_step(this); return false;">Next Step</button>
<div style="clear:both;"></div>
</div>
</div>
<div class='clearfix'></div>
</div>
<div class="mini_form" id="vehicle_information">
<h2 class="orange">Vehicle Information</h2>
<div class='row'>
<div class="col-sm-4">
Vehicle Year<br />
<select class='form-control' name="vehicle_year">
<option value=""></option>
<?php for($i=date('Y'); $i>=date('Y')-50; $i--) { ?>
<option value="<?= $i;?>" <?= ($_POST['vehicle_year']==$i) ? 'selected' : '';?>><?= $i;?></option>
<?php } ?>
</select>
</div>
<div class="col-sm-4">
Vehicle Make<br />
<input class='form-control' type="text" name="vehicle_make" value="<?= $_POST['vehicle_make'];?>" />
</div>
<div class="col-sm-4">
Vehicle Model<br />
<input class='form-control' type="text" name="vehicle_model" value="<?= $_POST['vehicle_model'];?>" />
</div>
</div>
<div class='row'>
<div class="col-sm-3 nopad">
Mileage<br />
<input class="number form-control" type="text" name="mileage" value="<?= $_POST['mileage'];?>" />
</div>
<div class="col-sm-3">
Color<br />
<input type="text" class="form-control" name="color" value="<?= $_POST['color'];?>" />
</div>
<div class="col-sm-3">
Licence Plate Number<br />
<input type="text" class="form-control" name="license_plate_number" value="<?= $_POST['license_plate_number'];?>" />
</div>
<div class="col-sm-3">
State of Registration<br />
<select name="state_of_registration" class="form-control">
<option>state</option>
<?php
$states = array('AL'=>'Alabama','AK'=>'Alaska','AZ'=>'Arizona','AR'=>'Arkansas','CA'=>'California','CO'=>'Colorado','CT'=>'Connecticut','DE'=>'Delaware','DC'=>'District of Columbia','FL'=>'Florida','GA'=>'Georgia','HI'=>'Hawaii','ID'=>'Idaho','IL'=>'Illinois','IN'=>'Indiana','IA'=>'Iowa','KS'=>'Kansas','KY'=>'Kentucky','LA'=>'Louisiana','ME'=>'Maine','MD'=>'Maryland','MA'=>'Massachusetts','MI'=>'Michigan','MN'=>'Minnesota','MS'=>'Mississippi','MO'=>'Missouri','MT'=>'Montana','NE'=>'Nebraska','NV'=>'Nevada','NH'=>'New Hampshire','NJ'=>'New Jersey','NM'=>'New Mexico','NY'=>'New York','NC'=>'North Carolina','ND'=>'North Dakota','OH'=>'Ohio','OK'=>'Oklahoma','OR'=>'Oregon','PA'=>'Pennsylvania','RI'=>'Rhode Island','SC'=>'South Carolina','SD'=>'South Dakota','TN'=>'Tennessee','TX'=>'Texas','UT'=>'Utah','VT'=>'Vermont','VA'=>'Virginia','WA'=>'Washington','WV'=>'West Virginia','WI'=>'Wisconsin','WY'=>'Wyoming');
foreach($states as $k=>$v) {
?><option value="<?= $k;?>" <?= ($_POST['state']==$k) ? 'selected' : '';?>><?= $v;?></option><?php
}
?>
</select>
</div>
</div>
<div class="form row">
<br>
<div class="col-sm-12 javascript_save_button" style="display:none;">
<button class="submit" style="float:right;padding:0px 10px;" onclick="save_step(this); return false;">Next Step</button>
<div style="clear:both;"></div>
</div>
</div>
<div class='clearfix'></div>
</div>
<div class="mini_form form" id="employment_information">
<h2 class="red">Employment Information</h2>
<div class="row">
<div class="col-sm-6">
Where do you work?<br />
<input type="text" class="form-control" name="employer" value="<?= $_POST['employer'];?>" />
</div>
<div class="col-sm-6 col-md-3">
Your position<br />
<input type="text" class="form-control" name="occupation" value="<?= $_POST['occupation'];?>" />
</div>
<div class="col-sm-6 col-md-3">
Employer's Phone Number<br />
<input type="tel" class="form-control phone_number" name="employer_phone" value="<?= $_POST['employer_phone'];?>" />
</div>
<div class="col-sm-6">
Work address<br />
<input type="text" class="form-control" name="work_address" value="<?= $_POST['work_address'];?>" />
</div>
<div class="col-sm-3 col-md-2">
City<br />
<input type="text" class="form-control" name="work_city" value="<?= $_POST['work_city'];?>" />
</div>
<div class="col-sm-3 col-md-2 nopad">
<div class="st">
State<br />
<select class="form-control" name="work_state">
<option>state</option>
<?php
$states = array('AL'=>'Alabama','AK'=>'Alaska','AZ'=>'Arizona','AR'=>'Arkansas','CA'=>'California','CO'=>'Colorado','CT'=>'Connecticut','DE'=>'Delaware','DC'=>'District of Columbia','FL'=>'Florida','GA'=>'Georgia','HI'=>'Hawaii','ID'=>'Idaho','IL'=>'Illinois','IN'=>'Indiana','IA'=>'Iowa','KS'=>'Kansas','KY'=>'Kentucky','LA'=>'Louisiana','ME'=>'Maine','MD'=>'Maryland','MA'=>'Massachusetts','MI'=>'Michigan','MN'=>'Minnesota','MS'=>'Mississippi','MO'=>'Missouri','MT'=>'Montana','NE'=>'Nebraska','NV'=>'Nevada','NH'=>'New Hampshire','NJ'=>'New Jersey','NM'=>'New Mexico','NY'=>'New York','NC'=>'North Carolina','ND'=>'North Dakota','OH'=>'Ohio','OK'=>'Oklahoma','OR'=>'Oregon','PA'=>'Pennsylvania','RI'=>'Rhode Island','SC'=>'South Carolina','SD'=>'South Dakota','TN'=>'Tennessee','TX'=>'Texas','UT'=>'Utah','VT'=>'Vermont','VA'=>'Virginia','WA'=>'Washington','WV'=>'West Virginia','WI'=>'Wisconsin','WY'=>'Wyoming');
foreach($states as $k=>$v) {
?><option value="<?= $k;?>" <?= ($_POST['work_state']==$k) ? 'selected' : '';?>><?= $v;?></option><?php
}
?>
</select>
</div>
</div>
<div class="zp col-sm-3 col-md-2">
Zip<br />
<input class='form-control' type="tel" maxlength="5" name="work_zip" value="<?= $_POST['work_zip'];?>" />
</div>
</div>
<div class='row'>
<div class="col-sm-6">
Supervisor<br />
<input class='form-control' type="text" name="supervisor" value="<?= $_POST['supervisor'];?>" />
</div>
<div class="col-sm-3 col-md-2 nopad">
Employed from<br />
<select class="dm form-control" name="employed_from_month">
<option>month</option>
<?php for($i=1;$i<=12;$i++) { ?>
<option value="<?= $i;?>" <?= ($_POST['employed_from_month']*1==$i) ? 'selected' : '';?>><?= date("F", mktime(0, 0, 0, $i, 10));?></option>
<?php } ?>
</select>
</div>
<div class='col-sm-3 col-md-2'>
<br>
<select class="dd form-control" name="employed_from_day">
<option>day</option>
<?php for($i=1;$i<=31;$i++) { ?>
<option value="<?= $i;?>" <?= ($_POST['employed_from_day']*1==$i) ? 'selected' : '';?>><?= $i;?></option>
<?php } ?>
</select>
</div>
<div class='col-sm-3 col-md-2'>
<br>
<select class="dy form-control" name="employed_from_year">
<option>year</option>
<?php for($i=(date('Y')*1); $i>= (date('Y')-30); $i--) { ?>
<option value="<?= $i;?>" <?= ($_POST['employed_from_year']*1==$i) ? 'selected' : '';?>><?= $i;?></option>
<?php } ?>
</select>
</div>
</div>
<div class='row'>
<div class="col-sm-6">
What is your take home amount per paycheck?<br />
<input class='form-control' type="number" name="take_home_amount_per_paycheck" value="<?= $_POST['take_home_amount_per_paycheck'];?>" />
</div>
<div class="col-sm-6">
How often do you get paid?<br />
<select class="form-control" name="how_often_paid" onchange="if($(this).val()=='Other') { $(this).next().next('input').show(); } else { $(this).next().next('input').hide(); }">
<option value="Select value">Select value</option>
<option value="Every Friday" <?= ($_REQUEST['how_often_paid']=='Every Friday') ? 'selected': '';?>>Every Friday</option>
<option value="Every Thursday" <?= ($_REQUEST['how_often_paid']=='Every Thursday') ? 'selected': '';?>>Every Thursday</option>
<option value="Every Wednesday" <?= ($_REQUEST['how_often_paid']=='Every Wednesday') ? 'selected': '';?>>Every Wednesday</option>
<option value="Every Tuesday" <?= ($_REQUEST['how_often_paid']=='Every Tuesday') ? 'selected': '';?>>Every Tuesday</option>
<option value="Every Monday" <?= ($_REQUEST['how_often_paid']=='Every Monday') ? 'selected': '';?>>Every Monday</option>
<option value="Every other Friday" <?= ($_REQUEST['how_often_paid']=='Every other Friday') ? 'selected': '';?>>Every other Friday</option>
<option value="Every other Thursday" <?= ($_REQUEST['how_often_paid']=='Every other Thursday') ? 'selected': '';?>>Every other Thursday</option>
<option value="Every other Wednesday" <?= ($_REQUEST['how_often_paid']=='Every other Wednesday') ? 'selected': '';?>>Every other Wednesday</option>
<option value="Every other Tuesday" <?= ($_REQUEST['how_often_paid']=='Every other Tuesday') ? 'selected': '';?>>Every other Tuesday</option>
<option value="Every other Monday" <?= ($_REQUEST['how_often_paid']=='Every other Monday') ? 'selected': '';?>>Every other Monday</option>
<option value="1st & 15th" <?= ($_REQUEST['how_often_paid']=='1st & 15th') ? 'selected': '';?>>1st & 15th</option>
<option value="15th & 31st" <?= ($_REQUEST['how_often_paid']=='15th & 31st') ? 'selected': '';?>>15th & 31st</option>
<option value="7th & 22nd" <?= ($_REQUEST['how_often_paid']=='7th & 22nd') ? 'selected': '';?>>7th & 22nd</option>
<option value="6th & 21st" <?= ($_REQUEST['how_often_paid']=='6th & 21st') ? 'selected': '';?>>6th & 21st</option>
<option value="Other" <?= ($_REQUEST['how_often_paid']=='Other') ? 'selected': '';?>>Other</option>
</select>
<br />
<input type="text" class="form-control" <?= ($_REQUEST['how_often_paid']=='Other') ? 'style="diplay:block;"' : 'style="display:none;"';?> name="how_often_paid_other" placeholder="How often do you get paid?" />
</div>
<div class="col-sm-6">
What is a confortable payment amount for you to make each payday?<br />
<input class='form-control' type="number" name="confortable_payment" value="<?= $_POST['confortable_payment'];?>" />
</div>
<div class="col-sm-6">
Are you currently disabled or receiving Social Security?<br />
<label class="radio-inline" for="disabled_yes"><input type="radio" name="disabled" class="checkbox" id="disabled_yes" value="yes" <?= ($_POST['disabled']=='yes') ? 'checked' : '';?> />Yes</label>
<label class="radio-inline" for="disabled_no"><input type="radio" name="disabled" class="checkbox" id="disabled_no" value="no" <?= ($_POST['disabled']=='no') ? 'checked' : '';?> />No</label>
</div>
<div class='clearfix'></div>
</div>
<div class="row">
<div class="col-sm-12">
Do you have a second source of income?<br />
<label class="radio-inline" for="second_source_of_income_yes"><input type="radio" name="second_source_of_income" class="checkbox" id="second_source_of_income_yes" value="yes" <?= ($_POST['second_source_of_income']=='yes') ? 'checked' : '';?> onclick="if($(this).is(':checked')) { $('#second_source_of_income_container').show(); } else { $('#second_source_of_income_container').hide(); }" />Yes</label>
<label class="radio-inline" for="second_source_of_income_no"><input type="radio" name="second_source_of_income" class="checkbox" id="second_source_of_income_no" value="no" <?= ($_POST['second_source_of_income']=='no') ? 'checked' : '';?> onclick="if($(this).is(':checked')) { $('#second_source_of_income_container').hide(); } else { $('#second_source_of_income_container').show(); }" />No</label>
</div>
</div>
<div id="second_source_of_income_container" style="display:none;">
<h2 class="red">Secondary Employment Information</h2>
<div class="row">
<div class="col-sm-6">
Where do you work?<br />
<input type="text" class="form-control" name="secondary_employer" value="<?= $_POST['secondary_employer'];?>" />
</div>
<div class="col-sm-6 col-md-3">
Your position<br />
<input type="text" class="form-control" name="secondary_occupation" value="<?= $_POST['secondary_occupation'];?>" />
</div>
<div class="col-sm-6 col-md-3">
Employer's Phone Number<br />
<input type="tel" class="form-control phone_number" name="secondary_employer_phone" value="<?= $_POST['secondary_employer_phone'];?>" />
</div>
<div class="col-sm-6">
Work address<br />
<input type="text" class="form-control" name="secondary_work_address" value="<?= $_POST['secondary_work_address'];?>" />
</div>
<div class="col-sm-3 col-md-2">
City<br />
<input type="text" class="form-control" name="secondary_work_city" value="<?= $_POST['secondary_work_city'];?>" />
</div>
<div class="col-sm-3 col-md-2 nopad">
<div class="st">
State<br />
<select class="form-control" name="secondary_work_state">
<option>state</option>
<?php
$states = array('AL'=>'Alabama','AK'=>'Alaska','AZ'=>'Arizona','AR'=>'Arkansas','CA'=>'California','CO'=>'Colorado','CT'=>'Connecticut','DE'=>'Delaware','DC'=>'District of Columbia','FL'=>'Florida','GA'=>'Georgia','HI'=>'Hawaii','ID'=>'Idaho','IL'=>'Illinois','IN'=>'Indiana','IA'=>'Iowa','KS'=>'Kansas','KY'=>'Kentucky','LA'=>'Louisiana','ME'=>'Maine','MD'=>'Maryland','MA'=>'Massachusetts','MI'=>'Michigan','MN'=>'Minnesota','MS'=>'Mississippi','MO'=>'Missouri','MT'=>'Montana','NE'=>'Nebraska','NV'=>'Nevada','NH'=>'New Hampshire','NJ'=>'New Jersey','NM'=>'New Mexico','NY'=>'New York','NC'=>'North Carolina','ND'=>'North Dakota','OH'=>'Ohio','OK'=>'Oklahoma','OR'=>'Oregon','PA'=>'Pennsylvania','RI'=>'Rhode Island','SC'=>'South Carolina','SD'=>'South Dakota','TN'=>'Tennessee','TX'=>'Texas','UT'=>'Utah','VT'=>'Vermont','VA'=>'Virginia','WA'=>'Washington','WV'=>'West Virginia','WI'=>'Wisconsin','WY'=>'Wyoming');
foreach($states as $k=>$v) {
?><option value="<?= $k;?>" <?= ($_POST['secondary_work_state']==$k) ? 'selected' : '';?>><?= $v;?></option><?php
}
?>
</select>
</div>
</div>
<div class="zp col-sm-3 col-md-2">
Zip<br />
<input class='form-control' type="tel" maxlength="5" name="secondary_work_zip" value="<?= $_POST['secondary_work_zip'];?>" />
</div>
</div>
<div class='row'>
<div class="col-sm-6">
Supervisor<br />
<input class='form-control' type="text" name="secondary_supervisor" value="<?= $_POST['secondary_supervisor'];?>" />
</div>
<div class="col-sm-3 col-md-2 nopad">
Employed from<br />
<select class="dm form-control" name="secondary_employed_from_month">
<option>month</option>
<?php for($i=1;$i<=12;$i++) { ?>
<option value="<?= $i;?>" <?= ($_POST['secondary_employed_from_month']*1==$i) ? 'selected' : '';?>><?= date("F", mktime(0, 0, 0, $i, 10));?></option>
<?php } ?>
</select>
</div>
<div class='col-sm-3 col-md-2'>
<br>
<select class="dd form-control" name="secondary_employed_from_day">
<option>day</option>
<?php for($i=1;$i<=31;$i++) { ?>
<option value="<?= $i;?>" <?= ($_POST['secondary_employed_from_day']*1==$i) ? 'selected' : '';?>><?= $i;?></option>
<?php } ?>
</select>
</div>
<div class='col-sm-3 col-md-2'>
<br>
<select class="dy form-control" name="secondary_employed_from_year">
<option>year</option>
<?php for($i=(date('Y')*1); $i>= (date('Y')-30); $i--) { ?>
<option value="<?= $i;?>" <?= ($_POST['secondary_employed_from_year']*1==$i) ? 'selected' : '';?>><?= $i;?></option>
<?php } ?>
</select>
</div>
</div>
<div class='row'>
<div class="col-sm-6">
What is your take home amount per paycheck?<br />
<input class='form-control' type="number" name="secondary_take_home_amount_per_paycheck" value="<?= $_POST['secondary_take_home_amount_per_paycheck'];?>" />
</div>
<div class="col-sm-6">
How often do you get paid?<br />
<select class="form-control" name="secondary_how_often_paid" onchange="if($(this).val()=='Other') { $(this).next().next('input').show(); } else { $(this).next().next('input').hide(); }">
<option value="Select value">Select value</option>
<option value="Every Friday" <?= ($_REQUEST['secondary_how_often_paid']=='Every Friday') ? 'selected': '';?>>Every Friday</option>
<option value="Every Thursday" <?= ($_REQUEST['secondary_how_often_paid']=='Every Thursday') ? 'selected': '';?>>Every Thursday</option>
<option value="Every Wednesday" <?= ($_REQUEST['secondary_how_often_paid']=='Every Wednesday') ? 'selected': '';?>>Every Wednesday</option>
<option value="Every Tuesday" <?= ($_REQUEST['secondary_how_often_paid']=='Every Tuesday') ? 'selected': '';?>>Every Tuesday</option>
<option value="Every Monday" <?= ($_REQUEST['secondary_how_often_paid']=='Every Monday') ? 'selected': '';?>>Every Monday</option>
<option value="Every other Friday" <?= ($_REQUEST['secondary_how_often_paid']=='Every other Friday') ? 'selected': '';?>>Every other Friday</option>
<option value="Every other Thursday" <?= ($_REQUEST['secondary_how_often_paid']=='Every other Thursday') ? 'selected': '';?>>Every other Thursday</option>
<option value="Every other Wednesday" <?= ($_REQUEST['secondary_how_often_paid']=='Every other Wednesday') ? 'selected': '';?>>Every other Wednesday</option>
<option value="Every other Tuesday" <?= ($_REQUEST['secondary_how_often_paid']=='Every other Tuesday') ? 'selected': '';?>>Every other Tuesday</option>
<option value="Every other Monday" <?= ($_REQUEST['secondary_how_often_paid']=='Every other Monday') ? 'selected': '';?>>Every other Monday</option>
<option value="1st & 15th" <?= ($_REQUEST['secondary_how_often_paid']=='1st & 15th') ? 'selected': '';?>>1st & 15th</option>
<option value="15th & 31st" <?= ($_REQUEST['secondary_how_often_paid']=='15th & 31st') ? 'selected': '';?>>15th & 31st</option>
<option value="7th & 22nd" <?= ($_REQUEST['secondary_how_often_paid']=='7th & 22nd') ? 'selected': '';?>>7th & 22nd</option>
<option value="6th & 21st" <?= ($_REQUEST['secondary_how_often_paid']=='6th & 21st') ? 'selected': '';?>>6th & 21st</option>
<option value="Other" <?= ($_REQUEST['secondary_how_often_paid']=='Other') ? 'selected': '';?>>Other</option>
</select>
<br />
<input type="text" class="form-control" <?= ($_REQUEST['secondary_how_often_paid']=='Other') ? 'style="diplay:block;"' : 'style="display:none;"';?> name="secondary_how_often_paid_other" placeholder="How often do you get paid?" />
</div>
<div class="col-sm-6">
What is a confortable payment amount for you to make each payday?<br />
<input class='form-control' type="number" name="secondary_confortable_payment" value="<?= $_POST['secondary_confortable_payment'];?>" />
</div>
<div class="col-sm-6">
Are you currently disabled or receiving Social Security?<br />
<label class="radio-inline" for="secondary_disabled_yes"><input type="radio" name="secondary_disabled" class="checkbox" id="secondary_disabled_yes" value="yes" <?= ($_POST['secondary_disabled']=='yes') ? 'checked' : '';?> />Yes</label>
<label class="radio-inline" for="secondary_disabled_no"><input type="radio" name="secondary_disabled" class="checkbox" id="secondary_disabled_no" value="no" <?= ($_POST['secondary_disabled']=='no') ? 'checked' : '';?> />No</label>
</div>
<div class='clearfix'></div>
</div>
</div>
<div class='clearfix'></div>
<div class="row">
<div class="col-sm-12 javascript_save_button" style="display:none;">
<button class="submit" style="float:right;padding:0px 10px;" onclick="save_step(this); return false;">Next Step</button>
<div style="clear:both;"></div>
</div>
</div>
</div>
<div class="mini_form" id="co_applicant_information">
<h2 class="green">Co-Applicant Information</h2>
<div class="form green">
<div class="row co_app_question">
<div class='col-sm-6'>
Will there be a co-applicant?<br />
<label class='radio-inline'><input type="radio" name="is_there_a_co_applicant" value="yes" onclick="$('.co_app_form').show('fast');" />Yes</label>
<label class='radio-inline'><input type="radio" name="is_there_a_co_applicant" value="no" onclick="$('.co_app_form').hide('fast');" />No</label>
</div>
</div>
<div class="form co_app_form" style="display:none;">
<div class='row'>
<div class='col-sm-12 col-md-6'>
<div class='row'>
<div class="col-sm-4 nopad">
First Name<br />
<input type="text" name="co_first_name" class="form-control" value="<?= $_POST['co_first_name'];?>" />
</div>
<div class="col-sm-4 nopad">
Middle Name<br />
<input type="text" name="co_middle_name" class="form-control" value="<?= $_POST['co_middle_name'];?>" />
</div>
<div class="col-sm-4 nopad">
Last Name<br />
<input type="text" name="co_last_name" class="form-control" value="<?= $_POST['co_last_name'];?>" />
</div>
</div>
<div class='row'>
<div class="col-sm-12">
Address<br />
<input type="text" name="co_address" value="<?= $_POST['co_address'];?>" class="form-control" />
</div>
<div class="col-sm-12">
Apt #<br />
<input type="text" name="co_address2" value="<?= $_POST['co_address2'];?>" class="form-control" />
</div>
<div class="col-sm-4">
City<br />
<input type="text" name="co_city" value="<?= $_POST['co_city'];?>" class="form-control" />
</div>
<div class="col-sm-4 nopad">
<div class="st">
State<br />
<select name="co_state" class="form-control">
<option>state</option>
<?php
$states = array('AL'=>'Alabama','AK'=>'Alaska','AZ'=>'Arizona','AR'=>'Arkansas','CA'=>'California','CO'=>'Colorado','CT'=>'Connecticut','DE'=>'Delaware','DC'=>'District of Columbia','FL'=>'Florida','GA'=>'Georgia','HI'=>'Hawaii','ID'=>'Idaho','IL'=>'Illinois','IN'=>'Indiana','IA'=>'Iowa','KS'=>'Kansas','KY'=>'Kentucky','LA'=>'Louisiana','ME'=>'Maine','MD'=>'Maryland','MA'=>'Massachusetts','MI'=>'Michigan','MN'=>'Minnesota','MS'=>'Mississippi','MO'=>'Missouri','MT'=>'Montana','NE'=>'Nebraska','NV'=>'Nevada','NH'=>'New Hampshire','NJ'=>'New Jersey','NM'=>'New Mexico','NY'=>'New York','NC'=>'North Carolina','ND'=>'North Dakota','OH'=>'Ohio','OK'=>'Oklahoma','OR'=>'Oregon','PA'=>'Pennsylvania','RI'=>'Rhode Island','SC'=>'South Carolina','SD'=>'South Dakota','TN'=>'Tennessee','TX'=>'Texas','UT'=>'Utah','VT'=>'Vermont','VA'=>'Virginia','WA'=>'Washington','WV'=>'West Virginia','WI'=>'Wisconsin','WY'=>'Wyoming');
foreach($states as $k=>$v) {
?><option value="<?= $k;?>" <?= ($_POST['co_state']==$k) ? 'selected' : '';?>><?= $v;?></option><?php
}
?>
</select>
</div>
</div>
<div class="zp col-sm-4">
Zip<br />
<input type="text" name="co_zip" value="<?= $_POST['co_zip'];?>" class="form-control" />
</div>
</div>
</div>
<div class='col-sm-12 col-md-6'>
<div class='row'>
<div class="col-sm-6">
Email<br />
<input type="text" name="co_email" value="<?= $_POST['co_email'];?>" class="form-control" />
</div>
<div class="col-sm-6">
Social Security<br />
<input type="tel" name="co_social_security" class="form-control ssn" value="<?= $_POST['co_social_security'];?>" />
</div>
</div>
<div class='row'>
<div class="col-sm-4">
Date of Birth<br />
<select class="dm form-control" name="co_dob_month">
<option>month</option>
<?php for($i=1;$i<=12;$i++) { ?>
<option value="<?= $i;?>" <?= ($_POST['co_dob_month']*1==$i) ? 'selected' : '';?>><?= date("F", mktime(0, 0, 0, $i, 10));?></option>
<?php } ?>
</select>
</div>
<div class='col-sm-4'>
<br>
<select class="dd form-control" name="co_dob_day">
<option>day</option>
<?php for($i=1;$i<=31;$i++) { ?>
<option value="<?= $i;?>" <?= ($_POST['co_dob_day']*1==$i) ? 'selected' : '';?>><?= $i;?></option>
<?php } ?>
</select>
</div>
<div class='col-sm-4'>
<br>
<select class="dy form-control" name="co_dob_year">
<option>year</option>
<?php for($i=(date('Y')*1-16); $i>= (date('Y')-100); $i--) { ?>
<option value="<?= $i;?>" <?= ($_POST['co_dob_year']*1==$i) ? 'selected' : '';?>><?= $i;?></option>
<?php } ?>
</select>
</div>
</div>
<div class='row'>
<div class="col-sm-6">
Home Phone<br />
<input type="tel" class="phone_number form-control" name="co_home_phone" value="<?= $_POST['co_home_phone'];?>" />
</div>
<div class="col-sm-6">
Cell Phone<br />
<input type="tel" class="phone_number form-control" name="co_cell_phone" value="<?= $_POST['co_cell_phone'];?>" />
</div>
<div class="col-sm-6">
Work Phone<br />
<input type="tel" class="phone_number form-control" name="co_work_phone" value="<?= $_POST['co_work_phone'];?>" />
</div>
</div>
</div>
</div>
<div class='row'>
<div class="col-sm-6 col-md-3">
Drivers License Number<br />
<input class='form-control' type="tel" maxlength="16" name="co_drivers_license_number" value="<?= $_POST['co_drivers_license_number'];?>" />
</div>
<div class="col-sm-6 col-md-3">
State Issued<br />
<select name="co_state_issued" class="form-control">
<option>state</option>
<?php
$states = array('AL'=>'Alabama','AK'=>'Alaska','AZ'=>'Arizona','AR'=>'Arkansas','CA'=>'California','CO'=>'Colorado','CT'=>'Connecticut','DE'=>'Delaware','DC'=>'District of Columbia','FL'=>'Florida','GA'=>'Georgia','HI'=>'Hawaii','ID'=>'Idaho','IL'=>'Illinois','IN'=>'Indiana','IA'=>'Iowa','KS'=>'Kansas','KY'=>'Kentucky','LA'=>'Louisiana','ME'=>'Maine','MD'=>'Maryland','MA'=>'Massachusetts','MI'=>'Michigan','MN'=>'Minnesota','MS'=>'Mississippi','MO'=>'Missouri','MT'=>'Montana','NE'=>'Nebraska','NV'=>'Nevada','NH'=>'New Hampshire','NJ'=>'New Jersey','NM'=>'New Mexico','NY'=>'New York','NC'=>'North Carolina','ND'=>'North Dakota','OH'=>'Ohio','OK'=>'Oklahoma','OR'=>'Oregon','PA'=>'Pennsylvania','RI'=>'Rhode Island','SC'=>'South Carolina','SD'=>'South Dakota','TN'=>'Tennessee','TX'=>'Texas','UT'=>'Utah','VT'=>'Vermont','VA'=>'Virginia','WA'=>'Washington','WV'=>'West Virginia','WI'=>'Wisconsin','WY'=>'Wyoming');
foreach($states as $k=>$v) {
?><option value="<?= $k;?>" <?= ($_POST['co_state_issued']==$k) ? 'selected' : '';?>><?= $v;?></option><?php
}
?>
</select>
</div>
<div class="col-sm-4 col-md-2">
Date Expires<br />
<select class="dm form-control" name="co_date_expires_month">
<option>month</option>
<?php for($i=1;$i<=12;$i++) { ?>
<option value="<?= $i;?>" <?= ($_POST['co_date_issued_month']*1==$i) ? 'selected' : '';?>><?= date("F", mktime(0, 0, 0, $i, 10));?></option>
<?php } ?>
</select>
</div>
<div class='col-sm-4 col-md-2'>
<br>
<select class="dd form-control" name="co_date_expires_day">
<option>day</option>
<?php for($i=1;$i<=31;$i++) { ?>
<option value="<?= $i;?>" <?= ($_POST['co_date_issued_day']*1==$i) ? 'selected' : '';?>><?= $i;?></option>
<?php } ?>
</select>
</div>
<div class='col-sm-4 col-md-2'>
<br>
<select class="dy form-control" name="co_date_expires_year">
<option>year</option>
<?php for($i=(date('Y')*1); $i<= (date('Y')*1+5); $i++) { ?>
<option value="<?= $i;?>" <?= ($_POST['co_date_issued_year']*1==$i) ? 'selected' : '';?>><?= $i;?></option>
<?php } ?>
</select>
</div>
</div>
<div class='row'>
<div class="col-sm-6">
Where do you work?<br />
<input type="text" class="form-control" name="co_employer" value="<?= $_POST['co_employer'];?>" />
</div>
<div class="col-sm-3">
Your position<br />
<input type="text" class="form-control" name="co_occupation" value="<?= $_POST['co_occupation'];?>" />
</div>
<div class="col-sm-3">
Employer's Number<br />
<input type="tel" class="phone_number form-control" name="co_employer_phone" value="<?= $_POST['co_employer_phone'];?>" />
</div>
</div>
<div class='row'>
<div class="col-sm-12 col-md-6">
Work address<br />
<input type="text" class="form-control" name="co_work_address" value="<?= $_POST['co_work_address'];?>" />
</div>
<div class="col-sm-4 col-md-2">
City<br />
<input type="text" class="form-control" name="co_work_city" value="<?= $_POST['co_work_city'];?>" />
</div>
<div class="col-sm-4 col-md-2">
<div class="st">
State<br />
<select class="form-control" name="co_work_state">
<option>state</option>
<?php
$states = array('AL'=>'Alabama','AK'=>'Alaska','AZ'=>'Arizona','AR'=>'Arkansas','CA'=>'California','CO'=>'Colorado','CT'=>'Connecticut','DE'=>'Delaware','DC'=>'District of Columbia','FL'=>'Florida','GA'=>'Georgia','HI'=>'Hawaii','ID'=>'Idaho','IL'=>'Illinois','IN'=>'Indiana','IA'=>'Iowa','KS'=>'Kansas','KY'=>'Kentucky','LA'=>'Louisiana','ME'=>'Maine','MD'=>'Maryland','MA'=>'Massachusetts','MI'=>'Michigan','MN'=>'Minnesota','MS'=>'Mississippi','MO'=>'Missouri','MT'=>'Montana','NE'=>'Nebraska','NV'=>'Nevada','NH'=>'New Hampshire','NJ'=>'New Jersey','NM'=>'New Mexico','NY'=>'New York','NC'=>'North Carolina','ND'=>'North Dakota','OH'=>'Ohio','OK'=>'Oklahoma','OR'=>'Oregon','PA'=>'Pennsylvania','RI'=>'Rhode Island','SC'=>'South Carolina','SD'=>'South Dakota','TN'=>'Tennessee','TX'=>'Texas','UT'=>'Utah','VT'=>'Vermont','VA'=>'Virginia','WA'=>'Washington','WV'=>'West Virginia','WI'=>'Wisconsin','WY'=>'Wyoming');
foreach($states as $k=>$v) {
?><option value="<?= $k;?>" <?= ($_POST['co_work_state']==$k) ? 'selected' : '';?>><?= $v;?></option><?php
}
?>
</select>
</div>
</div>
<div class="zp col-sm-4 col-md-2">
Zip<br />
<input class='form-control' type="tel" maxlength="5" name="co_work_zip" value="<?= $_POST['co_work_zip'];?>" />
</div>
</div>
<div class='row'>
<div class="col-sm-12 col-md-6">
Supervisor<br />
<input class='form-control' type="text" name="co_supervisor" value="<?= $_POST['co_supervisor'];?>" />
</div>
<div class="col-sm-4 col-md-2 nopad">
Employed from<br />
<select class="dm form-control" name="co_employed_from_month">
<option>month</option>
<?php for($i=1;$i<=12;$i++) { ?>
<option value="<?= $i;?>" <?= ($_POST['co_employed_from_month']*1==$i) ? 'selected' : '';?>><?= date("F", mktime(0, 0, 0, $i, 10));?></option>
<?php } ?>
</select>
</div>
<div class='col-sm-4 col-md-2'>
<br>
<select class="dd form-control" name="co_employed_from_day">
<option>day</option>
<?php for($i=1;$i<=31;$i++) { ?>
<option value="<?= $i;?>" <?= ($_POST['co_employed_from_day']*1==$i) ? 'selected' : '';?>><?= $i;?></option>
<?php } ?>
</select>
</div>
<div class='col-sm-4 col-md-2'>
<br>
<select class="dy form-control" name="co_employed_from_year">
<option>year</option>
<?php for($i=(date('Y')*1); $i>= (date('Y')-30); $i--) { ?>
<option value="<?= $i;?>" <?= ($_POST['co_employed_from_year']*1==$i) ? 'selected' : '';?>><?= $i;?></option>
<?php } ?>
</select>
</div>
</div>
<div class='row'>
<div class="col-sm-6">
Gross Income<br />
<input class='form-control' type="number" name="co_gross_income" value="<?= $_POST['co_gross_income'];?>" />
</div>
<div class="col-sm-6">
Net Income<br />
<input class='form-control' type="number" name="co_net_income" value="<?= $_POST['co_net_income'];?>" />
</div>
</div>
</div>
<br>
<div class="col-sm-12 javascript_save_button" style="display:none;">
<button class="submit" style="float:right;padding:0px 10px;" onclick="save_step(this); return false;">Next Step</button>
<div style="clear:both;"></div>
</div>
</div>
<div class='clearfix'></div>
</div>
<div class="mini_form" id="references">
<h2 class="orange">References</h2>
<?php for($i=1; $i<=3; $i++) { ?>
<div class="form row orange" style="margin-bottom:0px;">
<div class="col-sm-6">
Reference Name<br />
<input class='form-control' type="text" name="reference_name_<?= $i;?>" value="<?= $_POST['reference_name_'.$i];?>" />
</div>
<div class="col-sm-3">
Relation to you<br />
<input class='form-control' type="text" name="reference_relation_<?= $i;?>" value="<?= $_POST['reference_relation_'.$i];?>" />
</div>
<div class="col-sm-3">
Contact Number<br />
<input class='form-control phone_number' type="tel" name="reference_phone_<?= $i;?>" value="<?= $_POST['reference_phone_'.$i];?>" />
</div>
<div class="col-sm-3">
Address<br />
<input class='form-control' type="text" name="reference_address_<?= $i;?>" value="<?= $_POST['reference_address_'.$i];?>" />
</div>
<div class="col-sm-3">
City<br />
<input class='form-control' type="text" name="reference_city_<?= $i;?>" value="<?= $_POST['reference_city_'.$i];?>" />
</div>
<div class="col-sm-3">
State<br />
<select class="form-control" name="reference_state_<?= $i;?>">
<option>state</option>
<?php
$states = array('AL'=>'Alabama','AK'=>'Alaska','AZ'=>'Arizona','AR'=>'Arkansas','CA'=>'California','CO'=>'Colorado','CT'=>'Connecticut','DE'=>'Delaware','DC'=>'District of Columbia','FL'=>'Florida','GA'=>'Georgia','HI'=>'Hawaii','ID'=>'Idaho','IL'=>'Illinois','IN'=>'Indiana','IA'=>'Iowa','KS'=>'Kansas','KY'=>'Kentucky','LA'=>'Louisiana','ME'=>'Maine','MD'=>'Maryland','MA'=>'Massachusetts','MI'=>'Michigan','MN'=>'Minnesota','MS'=>'Mississippi','MO'=>'Missouri','MT'=>'Montana','NE'=>'Nebraska','NV'=>'Nevada','NH'=>'New Hampshire','NJ'=>'New Jersey','NM'=>'New Mexico','NY'=>'New York','NC'=>'North Carolina','ND'=>'North Dakota','OH'=>'Ohio','OK'=>'Oklahoma','OR'=>'Oregon','PA'=>'Pennsylvania','RI'=>'Rhode Island','SC'=>'South Carolina','SD'=>'South Dakota','TN'=>'Tennessee','TX'=>'Texas','UT'=>'Utah','VT'=>'Vermont','VA'=>'Virginia','WA'=>'Washington','WV'=>'West Virginia','WI'=>'Wisconsin','WY'=>'Wyoming');
foreach($states as $k=>$v) {
?><option value="<?= $k;?>" <?= ($_POST['reference_state_'.$i]==$k) ? 'selected' : '';?>><?= $v;?></option><?php
}
?>
</select>
</div>
<div class="col-sm-3">
Zip<br />
<input class='form-control' type="tel" maxlength="5" name="reference_zip_<?= $i;?>" value="<?= $_POST['reference_zip_'.$i];?>" />
</div>
<?php if($i==3) { ?>
<div class='clearfix'></div>
<br>
<div class="col-sm-12 javascript_save_button" style="display:none;">
<button class="submit" style="float:right;padding:0px 10px;" onclick="save_step(this); return false;">Next Step</button>
<div style="clear:both;"></div>
</div>
<?php }else{
echo "<div class='clearfix'></div>";
echo "<hr>";
} ?>
</div>
<?php } ?>
<div class='clearfix'></div>
</div>
<div class="mini_form" id="disposable_income_assessment">
<h2 class="red">Monthly Income and Expenses</h2>
<div class="form col-sm-12 red">
<table border="0" cellpadding="5" cellspacing="5">
<tr>
<td><strong>Total Net Income:*</strong></td>
<td><input class='form-control required' type="number" id="total_net" name="total_net" value="<?= $_POST['total_net'];?>" onkeyup="calculate_income();" /></td>
</tr>
<tr>
<td style="padding-left:20px;">Rent/Mortgage:</td>
<td><input class='form-control' type="number" id="rent_mortgage" name="rent_mortgage" value="<?= $_POST['rent_mortgage'];?>" onkeyup="calculate_income();" /></td>
</tr>
<tr>
<td style="padding-left:20px;">Auto Payments:</td>
<td><input class='form-control' type="number" id="auto_payment" name="auto_payment" value="<?= $_POST['auto_payment'];?>" onkeyup="calculate_income();" /></td>
</tr>
<tr>
<td style="padding-left:20px;">Insurance:</td>
<td><input class='form-control' type="number" id="insurance" name="insurance" value="<?= $_POST['insurance'];?>" onkeyup="calculate_income();" /></td>
</tr>
<tr>
<td style="padding-left:20px;">Phone:</td>
<td><input class='form-control' type="number" id="pay_phone" name="pay_phone" value="<?= $_POST['pay_phone'];?>" onkeyup="calculate_income();" /></td>
</tr>
<tr>
<td style="padding-left:20px;">Utilities:</td>
<td><input class='form-control' type="number" id="utilities" name="utilities" value="<?= $_POST['utilities'];?>" onkeyup="calculate_income();" /></td>
</tr>
<tr>
<td style="padding-left:20px;">Credit Cards:</td>
<td><input class='form-control' type="number" id="credit_card" name="credit_card" value="<?= $_POST['credit_card'];?>" onkeyup="calculate_income();" /></td>
</tr>
<tr>
<td style="padding-left:20px;">Food:</td>
<td><input class='form-control' type="number" id="food" name="food" value="<?= $_POST['food'];?>" onkeyup="calculate_income();" /></td>
</tr>
<tr>
<td style="padding-left:20px;">Misc/Other:</td>
<td><input class='form-control' type="number" id="misc_other" name="misc_other" value="<?= $_POST['misc_other'];?>" onkeyup="calculate_income();" /></td>
</tr>
<tr>
<td>Total Monthly Expenses:</td>
<td><input class='form-control' type="text" id="total_monthly" name="total_monthly" value="<?= $_POST['total_monthly'];?>" readonly="readonly" /></td>
</tr>
<tr>
<td>Disposable Monthly Expenses:<br />(less expenses)</td>
<td><input class='form-control' type="text" id="disposable_monthly_income" name="disposable_monthly_income" value="<?= $_POST['disposable_monthly_income'];?>" readonly="readonly" /></td>
</tr>
</table>
<div class="col-sm-12 javascript_save_button" style="display:none;">
<button class="submit" style="float:right;padding:0px 10px;" onclick="save_step(this); return false;">Next Step</button>
<div style="clear:both;"></div>
</div>
</div>
<div class='clearfix'></div>
</div>
<div class="mini_form form" id="bankruptcy">
<br>
<div class="row">
<div class="col-sm-12">
1. Have you ever filed Bankruptcy?
<label class='radio-inline'>
<input type="radio" name="bankruptcy" id="bankruptcy_yes" value="yes" <?= ($_POST['bankruptcy']=='yes') ? 'checked' : '';?> />
Yes
</label>
<label class='radio-inline'>
<input type="radio" name="bankruptcy" id="bankruptcy_no" value="no" <?= ($_POST['bankruptcy']=='no') ? 'checked' : '';?> />
No
</label>
</div>
<div class='col-lg-offset-1 col-lg-11 col-sm-12'>
<div class='col-sm-12'>
If Yes, Date Filed:
</div>
<div class="col-sm-4 col-md-2 nopad">
<select class="dm form-control" name="date_filed_month">
<option>month</option>
<?php for($i=1;$i<=12;$i++) { ?>
<option value="<?= $i;?>" <?= ($_POST['date_filed_month']*1==$i) ? 'selected' : '';?>><?= date("F", mktime(0, 0, 0, $i, 10));?></option>
<?php } ?>
</select>
</div>
<div class="col-sm-4 col-md-2 nopad">
<select class="dd form-control" name="date_filed_day">
<option>day</option>
<?php for($i=1;$i<=31;$i++) { ?>
<option value="<?= $i;?>" <?= ($_POST['date_filed_day']*1==$i) ? 'selected' : '';?>><?= $i;?></option>
<?php } ?>
</select>
</div>
<div class="col-sm-4 col-md-2 nopad">
<select class="dy form-control" name="date_filed_year">
<option>year</option>
<?php for($i=(date('Y')*1); $i>= (date('Y')-30); $i--) { ?>
<option value="<?= $i;?>" <?= ($_POST['date_filed_year']*1==$i) ? 'selected' : '';?>><?= $i;?></option>
<?php } ?>
</select>
</div>
<div class="col-sm-12 col-md-4 nopad">
<label class='radio-inline' style="white-space:nowrap; display:inline-block;"><input type="radio" name="bankruptcy_status" value="Dismissed" <?= ($_POST['bankruptcy_status']=='Dismissed') ? 'checked' : '';?> />Dismissed</label>
<label class='radio-inline' style="white-space:nowrap; display:inline-block;"><input type="radio" name="bankruptcy_status" value="Discharged" <?= ($_POST['bankruptcy_status']=='Discharged') ? 'checked' : '';?> />Discharged</label>
<label class='radio-inline' style="white-space:nowrap; display:inline-block;"><input type="radio" name="bankruptcy_status" value="Pending" <?= ($_POST['bankruptcy_status']=='Pending') ? 'checked' : '';?> />Pending</label>
</div>
</div>
<div class="col-sm-12">
2. Are you party to any Suit or Legal Action, or are there any unsatisfied judgements against you?
<div class='col-sm-12'>
<label class='radio-inline'>
<input type="radio" name="legal_action" id="legal_action_yes" value="yes" <?= ($_POST['legal_action']=='yes') ? 'checked' : '';?> />
Yes
</label>
<label class='radio-inline'>
<input type="radio" name="legal_action" id="legal_action_no" value="no" <?= ($_POST['legal_action']=='no') ? 'checked' : '';?> />
No
</label>
</div>
</div>
<div class="col-sm-12">
3. Are you a member of the Armed Forces or a dependant of such?
<div class='col-sm-12'>
<label class='radio-inline'>
<input type="radio" name="military" id="military_yes" value="yes" <?= ($_POST['military']=='yes') ? 'checked' : '';?> />
Yes
</label>
<label class='radio-inline'>
<input type="radio" name="military" id="military_no" value="no" <?= ($_POST['military']=='no') ? 'checked' : '';?> />
No
</label>
</div>
</div>
<div class="row extra_info signature payday">
<div class="col-sm-12">
4. Have you applied for any other loans in the last 6 months?
<label class='radio-inline'>
<input type="radio" name="applied_for_other_loans_last_6_months" id="applied_for_other_loans_last_6_months_yes" value="yes" <?= ($_POST['applied_for_other_loans_last_6_months']=='yes') ? 'checked' : '';?> />
Yes
</label>
<label class='radio-inline'>
<input type="radio" name="applied_for_other_loans_last_6_months" id="applied_for_other_loans_last_6_months_no" value="no" <?= ($_POST['applied_for_other_loans_last_6_months']=='no') ? 'checked' : '';?> />
No
</label>
</div>
<div class="col-sm-12">
5. Do you have any outstanding payday, signature, or title loans?
<label class='radio-inline'>
<input type="radio" name="other_outstanding_loans" id="other_outstanding_loans_yes" value="yes" <?= ($_POST['other_outstanding_loans']=='yes') ? 'checked' : '';?> />
Yes
</label>
<label class='radio-inline'>
<input type="radio" name="other_outstanding_loans" id="other_outstanding_loans_no" value="no" <?= ($_POST['other_outstanding_loans']=='no') ? 'checked' : '';?> />
No
</label>
</div>
<div class='col-lg-offset-1 col-lg-11 col-sm-12'>
<div class="col-sm-12 col-md-4 nopad">
If Yes, Who is your loan with?
<input class='form-control' type="text" name="outstanding_loan_with_who" value="<?= $_POST['outstanding_loan_with_who'];?>" />
</div>
<div class="col-sm-12 col-md-5 nopad">
What is your remaining balance?
<input class='form-control' type="text" name="outstanding_loan_amount" value="<?= $_POST['outstanding_loan_amount'];?>" />
</div>
</div>
</div>
<div class='clearfix'></div>
<br>
<div class="col-sm-12 javascript_save_button" style="display:none;">
<button class="submit" style="float:right;padding:0px 10px;" onclick="save_step(this); return false;">Next Step</button>
<div style="clear:both;"></div>
</div>
</div>
<div class='clearfix'></div>
</div>
<div class="mini_form" id="bank_account_information">
<h2 class="orange">Bank Account Information</h2>
<small>The bank information is not required at this stage of the loan, but will speed up the process to receiving the money for the loan.</small>
<div class='row'>
<div class="col-sm-12">
Bank Name<br />
<input class="form-control" type="text" name="bank_name" value="<?= $_REQUEST['bank_name'];?>" />
</div>
</div>
<div class="row">
<div class="col-sm-6">
Bank Routing Number<br />
<input class="form-control" type="text" name="bank_routing_number" value="<?= $_REQUEST['bank_routing_number'];?>" />
</div>
<div class="col-sm-6">
Checking Account Number<br />
<input class="form-control" type="text" name="bank_checking_account_number" value="<?= $_REQUEST['bank_checking_account_number'];?>" />
</div>
</div>
<div class='row'>
<div class="col-sm-6">
How long have you had this account?<br />
<div class='col-sm-6'>
<input type="number" class="form-control" name="bank_had_account_since_num" value="<?= $_REQUEST['bank_had_account_since_num'];?>" />
</div>
<div class='col-sm-6'>
<select class="form-control" name="bank_had_account_since_type">
<option value="Months" <?= ($_REQUEST['bank_had_account_since_type']=='Months') ? 'selected' : '';?>>Months</option>
<option value="Years" <?= ($_REQUEST['bank_had_account_since_type']=='Years') ? 'selected' : '';?>>Years</option>
</select>
</div>
</div>
<div class="col-sm-6">
Are you paid via Direct Deposit?<br />
<label class='radio-inline'>
<input type="radio" name="bank_has_direct_deposit" id="bank_has_direct_deposit_yes" value="yes" <?= ($_POST['bank_has_direct_deposit']=='yes') ? 'checked' : '';?> />
Yes
</label>
<label class='radio-inline'>
<input type="radio" name="bank_has_direct_deposit" id="bank_has_direct_deposit_no" value="no" <?= ($_POST['bank_has_direct_deposit']=='no') ? 'checked' : '';?> />
No
</label>
</div>
</div>
<div class="form row">
<br>
<div class="col-sm-12 javascript_save_button" style="display:none;">
<button class="submit" style="float:right;padding:0px 10px;" onclick="save_step(this); return false;">Next Step</button>
<div style="clear:both;"></div>
</div>
</div>
<div class='clearfix'></div>
</div>
<div class="mini_form" id="signatures">
<div class="form row orange">
<div class="col-sm-12">
<center style="font-size:14px; font-weight:bold;">Acknowledgment</center>
<div class="extra_info">By signing below, applicant(s) acknowledge by his/her obligation to offer a true representation of the above information, and any misrepresentation will be considered fraudulant in nature. Applicant(s) understandings that should a default in payment occur, friends, relatives, and employers may be contacted.</p>
<div class="extra_info">BY TYPING YOUR NAME IN THE BOXES BELOW, YOU CERTIFY THAT THE INFORMATION ABOVE IS COMPLETELY TRUTHFUL, AND UNDERSTAND THAT LYING TO OBTAIN CREDIT IS A CRIME PUNISHABLE BY LAW. YOU ALSO AGREE THAT YOU HAVE THE ABILITY TO REPAY THE LOAN. YOU ALSO FULLY AUTHORIZE FAST TRACK LOANS, LLC TO VERIFY THE TRUTHFULNESS OF THE ABOVE INFORMATION BY ANY MEANS NECESSARY INCLUDING FAX OR CALLING ANY PERSON OR FIRM LISTED ABOVE. YOU FULLY RELEASE ALL PARTIES FROM ANY AND ALL DAMAGES THAT MAY RESULT. ANY FALSE STATEMENT MADE BY YOU SHALL BE SUFFICIENT GROUNDS FOR REJECTION OF YOUR APPLICATION. YOU CERTIFY THAT YOU ARE NOT IN OR CONTEMPLATING NOR HAVE SPOKEN WITH ANY ATTORNEY REGARDING PERSONAL BANKRUPTCY, AND THAT YOU DO NOT PLAN TO GO THROUGH OR FILE BANKRUPTCY IN THE NEXT SIX MONTHS. YOU CERTIFY THAT YOU HAVE READ AND UNDERSTOOD THE ABOVE STATEMENTS. YOU ACKNOWLEDGE THAT THIS APPLICATION AND ANY SUPPORTING DOCUMENTS PROVIDED WITH IT ARE PROPERTY OF FAST TRACK LOANS, LLC. YOU ALSO AUTHORIZE FAST TRACK LOANS, LLC TO DO A CREDIT CHECK AT ANY TIME DURING YOUR APPLICATION FOR CREDIT AND UNTIL YOUR LOAN IS PAID IN FULL.</div>
</div>
<br />
<div class="col-sm-6">
Signature of Applicant<br />
<input class='form-control' type="text" name="document_signature" id="document_signature" value="<?= $_POST['document_signature'];?>" />
</div>
<div class="col-sm-6">
Date<br />
<input class='form-control' type="text" name="document_date" value="<?= date('F j, Y');?>" disabled="disabled" />
</div>
<div class="col-sm-6">
Signature of Co-Applicant<br />
<input class='form-control' type="text" name="co_document_signature" id="co_document_signature" value="<?= $_POST['co_document_signature'];?>" />
</div>
<div class="col-sm-6">
Date<br />
<input class='form-control' type="text" name="codocument_date" value="<?= date('F j, Y');?>" disabled="disabled" />
</div>
<div class='clearfix'></div>
<br>
<div class="col-sm-12 javascript_save_button" style="display:none;">
<button class="submit" style="float:right;padding:0px 10px;" onclick="save_step(this); return false;">Finish</button>
<div style="clear:both;"></div>
</div>
</div>
<div class='clearfix'></div>
</div>
<div class="col-sm-12 no_javascript_save_button">
<input type="submit" name="submit" class="submit button button-primary" value="SUBMIT" style="display:block; width:400px; margin:0px auto;" />
</div>
<input type="hidden" name="form_type" value="col-sm-12_application" />
</form>
</div>
</div>
<script type='text/javascript'>
function loadForm(){
$('.javascript_save_button').show();
$('.no_javascript_save_button').hide();
$('#vehicle_information').hide();
$('#employment_information').hide();
$('#co_applicant_information').hide();
$('#references').hide();
$('#disposable_income_assessment').hide();
$('#bankruptcy').hide();
$('#bank_account_information').hide();
$('#signatures').hide();
<?php if(!empty($_POST['type_of_loan'])) { ?>
$('[name=type_of_loan]').each(function() {
if($(this).attr('value')=='<?= $_POST['type_of_loan'];?>') {
$(this).click();
}
});
<?php } ?>
}
</script>
<?php
$page = 'apply';
$form = 'none';
$pageHtml = ob_get_clean();
include 'includes/layout.php';