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<?php
require_once($_SERVER['DOCUMENT_ROOT'].'/assets/includes/php_header.php');
?>
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta name="viewport" content="width=device-width; initial-scale=1.0; maximum-scale=1.0; user-scalable=0;">
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<title><?=($title) ? $_SITE_NAME.' : '.$title : $_SITE_NAME;?></title>
<link type="text/css" rel="stylesheet" href="style.css" />
<script type="text/javascript" src="/mobile/js/jquery-1.9.1.min.js"></script>
<script src="/v7/js/jquery.formatter.min.js"></script>
<script src="/mobile/js/form.js"></script>
</head>
<script type="text/javascript" language="JavaScript">
function valid_email(email) {
if(/(.+)@(.+){2,}\.(.+){2,}/.test(email)) {
return true;
} else {
return false;
}
}
function validate_step(step) {
var error = 'Please fix the problems below:'+"\n\n";
var success = true;
if(success) {
return true;
} else {
return error;
}
}
$('document').ready(function() {
$('input[name=phone_full]').formatter({
'pattern': '({{999}}) {{999}}-{{9999}}',
'persistent': false
});
});
function checkZip(zip) {
zip = zip.replace(/[^0-9]/g,'');
if(zip.length==5) {
var str = 'zip='+encodeURIComponent(zip);
$.ajax
({
cache: false,
type: "POST",
dataType:"json",
data: str,
url: "/php/ZipToCity.php",
success: function(data)
{
if(!data.error) {
$('[name=cc_city]').val(data.city);
$('[name=cc_state]').val(data.state);
}
},error: function(jqXHR, textStatus, errorThrown) {
}
});
}
}
</script>
<body>
<div class="logo"></div><!-- #logo -->
<div class="logo_trim"></div><!-- #logo_trim -->
<div id="form-area">
<div id="body-content">
<form id="form" action="/order.php" method="post" name="application" target="_top" onSubmit="var validated = validate_step(); if(validated === true) { return true; } else { alert(validated); return false; }">
<div id="one-step">
<h5>Progress: <progress value="11.1" max="100"></progress></h5>
<div>
<div style="margin-bottom: 20px;" class="label">Tell us what type of grants you are interested in?</div>
<div>
<label> <input type="radio" name="category_id" id="1-business" class="radio" value="1"/>
<label for="1-business">Business Funding</label>
</div>
<div>
<input type="radio" name="category_id" id="5-real-estate" class="radio" value="5"/>
<label for="5-real-estate">Real Estate</label>
</div>
<div>
<input type="radio" name="category_id" id="3-community" class="radio" value="3"/>
<label for="3-community">Community Funding</label>
</div>
<div>
<input type="radio" name="category_id" id="2-education" class="radio" value="2"/>
<label for="2-education">Education</label>
</div>
<div>
<input type="radio" name="category_id" id="6-1st-time-home-buyer" class="radio" value="6"/>
<label for="6-1st-time-home-buyer">Real Estate</label>
</div>
<div>
<input type="radio" name="category_id" id="4-personal" class="radio" value="4"/>
<label for="4-personal">Personal Assistance</label>
</div>
</div>
</div><!-- end 1 -->
<div id="two-step">
<h5>Progress: <progress value="22.2" max="100"></h5>
<div>
<div style="margin-bottom: 20px;" class="label">How much money are you looking for?</div>
<div>
<input type="radio" name="app_amount_needed" id="radio7" class="radio" value="$500 - $10,000"/>
<label for="radio7">$500 - $10,000</label>
</div>
<div>
<input type="radio" name="app_amount_needed" id="radio8" class="radio" value="$10,000 - $25,000"/>
<label for="radio8">$10,000 - $25,000</label>
</div>
<div>
<input type="radio" name="app_amount_needed" id="radio9" class="radio" value="$25,000 - $50,000" />
<label for="radio9">$25,000 - $50,000</label>
</div>
<div>
<input type="radio" name="app_amount_needed" id="radio10" class="radio" value="$50,000 - $100,000"/>
<label for="radio10">$50,000 - $100,000</label>
</div>
<div>
<input type="radio" name="app_amount_needed" id="radio11" class="radio" value="$100,000 or More"/>
<label for="radio11">$100,000 or More</label>
</div>
</div>
</div> <!-- end 2 -->
<div id="three-step">
<h5>Progress: <progress value="33.3" max="100"></h5> <div style="margin-bottom: 20px;" class="label">Tell us about yourself?</div>
<p>Gender:</p>
<div>
<input type="radio" name="app_gender" id="radio12" class="radio" value="M"/>
<label for="radio12">Male</label>
</div>
<div>
<input type="radio" name="app_gender" id="radio13" class="radio" value="F"/>
<label for="radio13">Female</label>
</div>
<p style="margin-top:30px;">Age:</p>
<input class="age" type="tel" maxlength="3" name="app_age" value="<?= $_REQUEST['app_age'];?>" />
</div> <!-- end 3 -->
<div id="four-step">
<h5>Progress: <progress value="44.4" max="100"></h5>
<div style="margin-bottom: 20px;" class="label">Describe in detail how you'll use the money:</div>
<br/>
<textarea style="height: 120px;" name="app_usedescription"><?= (isset($_REQUEST['app_usedescription'])) ? $_REQUEST['app_usedescription'] : null;?></textarea>
</div> <!-- end 4 -->
<div id="five-step">
<h5>Progress: <progress value="55.5" max="100"></h5>
<div style="margin-bottom: 20px;" class="label">What makes you the ideal candidate for this funding opportunity?:</div>
<br/>
<textarea style="height: 120px;" name="app_uniqueness"><?= (isset($_REQUEST['app_uniqueness'])) ? $_REQUEST['app_uniqueness'] : null;?></textarea>
</div> <!-- end 5 -->
<div id="six-step">
<h5>Progress: <progress value="66.6" max="100"></h5>
<div style="margin-bottom: 20px;" class="label">Tell us about yourself:</div>
<p>First Name:</p>
<input type="text" name="cc_fname" id="cc_fname" value="<?= $_REQUEST['cc_fname'];?>" />
<br/>
<p>Last Name:</p>
<input type="text" name="cc_lname" id="cc_lname" value="<?= $_REQUEST['cc_lname'];?>" />
</div> <!-- end 6 -->
<div id="seven-step">
<h5>Progress: <progress value="77.7" max="100"></h5>
<div style="margin-bottom: 20px;" class="label">Tell us about yourself:</div>
<p>Phone:</p>
<input type="tel" name="phone_full" id="phone_full" value="<?= $_REQUEST['phone_full'];?>" />
<br/>
<p>Email:</p>
<input type="text" name="cc_email" id="cc_email" value="<?= $_REQUEST['cc_email'];?>" />
</div> <!-- end 7 -->
<div id="eight-step">
<h5>Progress: <progress value="88.8" max="100"></h5>
<div style="margin-bottom: 20px;" class="label">Tell us about yourself:</div>
<p>Address:</p>
<input type="text" class="full" name="cc_addr" value="<?= isset($_REQUEST['cc_addr']) ? $_REQUEST['cc_addr'] : null;?>" />
<br/>
<p>Zip Code:</p>
<input type="tel" name="cc_zip" maxlength="5" id="lname" onkeyup="checkZip($(this).val());" value="<?= $_REQUEST['cc_zip'];?>" />
</div> <!-- end 7 -->
<div id="last-step">
<h5>Progress: <progress value="98" max="100"></h5>
<p>City</p>
<input type="text" name="cc_city" id="cc_city" value="<?= $_REQUEST['cc_city'];?>" />
<br/>
<p>State:</p>
<input type="text" name="cc_state" id="cc_state" value="<?= $_REQUEST['cc_state'];?>" />
<input type="hidden" name="form_version" value="v7" />
<input type="hidden" name="form_filled_out" value="/mobile/index.php" />
<input type="hidden" id="granttype_input" name="granttype" value="<?= (isset($_REQUEST['granttype'])) ? $_REQUEST['granttype'] : null; ?>" />
<input type="hidden" name="application" value="application" />
<input type="hidden" name="tc" value="<?= $tc; ?>" />
<?= $trackerformparams; ?>
<input type="submit" value="Register" style="background-color: #0e2d5a; padding: 15px 15px 40px 15px; color: #fff; top center no-repeat;width:100%;height:39px;border:0px;margin:20px 0px 0px 5px; cursor:pointer">
</div> <!-- end 9 -->
</form>
</div>
</div><!-- #form-area -->
<div id="footer">
<a href="https://newusafunding.com/terms.php">Terms</a> | <a href="https://newusafunding.com/privacy.php">Privacy</a> | <a href="https://newusafunding.com/login.php">Member Login</a> | <a href="https://newusafunding.com/contact.php">Contacts</a>
</div>
</body>
<img src="https://www.surfcrm.com/lcapi/FormImpressionTracking.php?site=agf&ip_address=<?= $_SERVER['REMOTE_ADDR'];?>&form_url=<?= urlencode('/mobile/index.php');?>" />
<script type="text/javascript">
window.setTimeout(function() {
var form_session = new Image();
form_session.src = "https://www.surfcrm.com/lcapi/FormSessionTracking.php?site=agf&ip_address=<?= $_SERVER['REMOTE_ADDR'];?>&form_url=<?= urlencode('/mobile/index.php');?>";
},3000);
</script>