@include('dashboard.layouts.header')

<!-- Content Wrapper. Contains page content -->
<div class="content-wrapper">
  <!-- Content Header (Page header) -->
  <section class="content-header">
    <div class="container-fluid">
      <div class="row mb-2">
        <div class="col-sm-6">
          <h1>Beauty Salon License Florida</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">Beauty Salon License Florida</li>
          </ol>
        </div>
      </div>
    </div><!-- /.container-fluid -->
  </section>

  <!-- Main content -->
  <section class="content">
    <div class="container-fluid">
      <div class="row">
        <!-- left column -->
        <div class="col-md-12">
          <!-- general form elements -->
          <div class="card card-primary">
            <div class="card-header">
              <h3 class="card-title">Beauty Salon License Florida</h3>
            </div>
            </br>
            @if (session('success'))
            <div class="alert alert-success">
              {{ session('success') }}
            </div>
            @endif
            @if(isset($report))
            <form action="{{ route('beauty-salon-license-florida-submit-form.update', $report->id) }}" method="POST" onsubmit="disableButton()">
              @csrf
              @method('PUT')
              @else
              <form action="{{ route('beauty-salon-license-florida-submit-form') }}" method="POST" onsubmit="disableButton()">
                @csrf
                @endif
                <div class="card-body">
                  <!-- Contact Information Section -->
                  <h3>Contact Information</h3>
                  <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="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="suiteApt">Suite/Apt</label>
                        <input type="text" value="{{ old('suite_apt', $report->suite_apt ?? '') }}" class="form-control" name="suite_apt" id="suiteApt" placeholder="Enter Suite/Apt">
                      </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="email">Email</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 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>
                  <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>


                  <!-- Company Information Section -->
                  <h3>Company Information</h3>
                  <div class="row">
                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="entityName">Name of Entity</label>
                        <input type="text" value="{{ old('entity_name', $report->entity_name ?? '') }}" class="form-control" name="entity_name" id="entityName" placeholder="Enter Name of Entity">
                      </div>
                      <div class="form-group">
                        <label for="einNumber">EIN Number</label>
                        <input type="text" value="{{ old('ein_number', $report->ein_number ?? '') }}" class="form-control" name="ein_number" id="einNumber" placeholder="Enter EIN Number">
                      </div>

                      <div class="form-group">
                        <label for="licenseEffectiveDate">License to be effective on</label>
                        <input type="date" value="{{ old('license_effective_date', $report->license_effective_date ?? '') }}" class="form-control" name="license_effective_date" id="licenseEffectiveDate">
                      </div>

                      <div class="form-group">
                        <label for="companySuiteApt">Suite/Apt</label>
                        <input type="text" value="{{ old('company_suite_apt', $report->company_suite_apt ?? '') }}" class="form-control" name="company_suite_apt" id="companySuiteApt" placeholder="Enter Suite/Apt">
                      </div>

                    </div>

                    <div class="col-md-6 col-print-6">
                      <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 of Formation">
                      </div>

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

                  </div>

                  <div class="row">
                    <div class="col-md-12">
                      <div class="form-group">
                        <label for="companyAddress">Address</label>
                        <input type="text" value="{{ old('company_address', $report->company_address ?? '') }}" class="form-control" name="company_address" id="companyAddress" placeholder="Enter Address">
                      </div>
                    </div>
                  </div>

                  <!-- Shareholder/Officers/Members Information Section -->
                  <h3>Shareholder/Officers/Members Information</h3>

                  <!-- Shareholder 1 -->
                  <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>

                  <!-- Contract Section -->
                  <h3>Contract</h3>
                  <div class="row">
                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="paymentAmount">Payment Amount</label>
                        <input type="text" value="{{ old('payment_amount', $report->payment_amount ?? '') }}" class="form-control" name="payment_amount" id="paymentAmount" placeholder="Enter Payment Amount">
                      </div>
                    </div>

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

                <div class="card-footer">
                  <button type="submit" class="btn btn-primary" id="submitButton">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);
    });

  });
</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>