GRM COMPLAINT FORM

@if ($message = Session::get('success'))

@elseif ($message = Session::get('error'))

@endif @if (count($errors) > 0)

Whoops! There were some problems with your input.

{{ $error }}

@endif {!! Form::open(array('route' => 'complaintsubmit','method'=>'POST', 'files'=>'true', 'class'=>'form-horizontal')) !!}

Complainant Information {{--

{!! Form::select('source_channel', $source_channels, null, ['placeholder' => 'Source/Channel', 'class' => 'form-control select2', 'required']) !!}

--}} {!! Form::hidden('source_channel', 1) !!}

{!! Form::select('piu', $pius, 2, ['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')) !!} {{--(9999) 999-9999--}}

{!! 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']) !!}

Postal Address

{!! 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

Upload any Evidence File

{!! Form::file('evidence_files[]', null, array('class' => '')) !!}

Upload Any Photo

{!! Form::file('evidence_photos[]', null, array('class' => '')) !!}

Upload Any Video

{!! Form::file('evidence_videos[]', null, array('class' => '')) !!}

Upload Scan Copy of the Grievance received by Hand

{!! Form::file('evidence_scan_copy_grievance_hands[]', null, array('class' => '')) !!}

{!! Form::close() !!}