@extends('dashboard.layout.master') @section('content')
@include('dashboard.layout.navbar')
GRM Complaint Form
@if (count($errors) > 0)
Whoops! There were some problems with your input.

    @foreach ($errors->all() as $error)
  • {{ $error }}
  • @endforeach
@endif {!! Form::open(array('route' => 'complaints.store','method'=>'POST', 'files'=>'true', 'class'=>'')) !!}
Complainant Information
{!! Form::select('source_channel', $source_channels, null, ['placeholder' => 'Source/Channel', 'class' => 'form-control select2', 'required']) !!}
{!! Form::select('piu', $pius, null, ['placeholder' => 'Select PIU', 'class' => 'form-control select2', 'required']) !!}
Personal Details
{!! Form::text('full_name', null, array('placeholder' => 'Full Name','class' => 'form-control', 'required')) !!}
{!! Form::text('father_name', null, array('placeholder' => 'Father Name','class' => 'form-control', 'required')) !!}
{!! Form::text('cnic', null, array('placeholder' => 'CNIC No','class' => 'form-control', 'id' => 'mask_cnic', 'required')) !!} 99999-9999999-9
{!! Form::text('hru_beneficiary_id', null, array('placeholder' => 'HRU Beneficiary ID','class' => 'form-control')) !!}
{!! Form::text('mobile', null, array('placeholder' => 'Mobile No','class' => 'form-control', 'maxlength' => '13', 'required')) !!}
{!! Form::email('email', null, array('placeholder' => 'Email ID (If Any)', 'class' => 'form-control')) !!}
{!! Form::select('gender', ['male'=>'Male', 'female'=>'Female', 'other'=>'Other'], null, ['placeholder' => 'Select Gender', 'class' => 'form-control', 'required']) !!}
{!! Form::select('district_id', $districts, null, array('placeholder' => 'Select District', 'class' => 'district form-control select2', 'required')) !!}
{!! Form::select('tehsil_id', [], null, ['placeholder' => 'Select Tehsil', 'class' => 'form-control select2', 'required']) !!}
{!! Form::select('uc_id', [], null, ['placeholder' => 'Select UC', 'class' => 'form-control select2', 'required']) !!}
{!! Form::textarea('postal_address', null, array('placeholder' => 'Postal Address', 'class' => 'form-control')) !!}
Grievance Registration
{!! Form::select('grievance_type', $grievance_types, null, ['placeholder' => 'Grievance Type', 'class' => 'grievance_type form-control select2', 'required']) !!}
Evidences
{!! Form::file('evidence_files[]', null, array('class' => '')) !!}
{!! Form::file('evidence_photos[]', null, array('class' => '')) !!}
{!! Form::file('evidence_videos[]', null, array('class' => '')) !!}
{!! Form::file('evidence_scan_copy_grievance_hands[]', null, array('class' => '')) !!}
{{--
--}}
@push('ayiscss') @endpush @push('ayisscript') @endpush @if(session('error')) @endif @if(session('success')) @endif @endsection