@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>Certificate of Amendment</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">Certificate of Amendment</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">Certificate of Amendment</h3>
            </div>
            </br>
            @if (session('success'))
            <div class="alert alert-success">
              {{ session('success') }}
            </div>
            @endif
            @if(isset($report))
            <form action="{{ route('certificate-of-amendment-submit-form.update', $report->id) }}" method="POST" onsubmit="disableButton()">
              @csrf
              @method('PUT')
              @else
              <form action="{{ route('certificate-of-amendment-submit-form') }}" method="POST" onsubmit="disableButton()">
                @csrf
                @endif
                <div class="card-body">
                  <!-- Contact Information -->
                  <h4>Contact Information</h4>
                  <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="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="suite">Suite/Apt</label>
                        <input type="text" value="{{ old('suite_apt', $report->suite_apt ?? '') }}" class="form-control" name="suite_apt" id="suite_apt" placeholder="Enter suite/apt">
                      </div>
                    </div>
                  </div>
                  <div class="row">
                    <div class="col-md-6 col-print-6">
                      <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="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 class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="email">Email address</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>

                  </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>


                  <h4>Company Information</h4>
                  <div class="row">
                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="companyName">Name of Entity</label>
                        <input type="text" value="{{ old('company_name', $report->company_name ?? '') }}" class="form-control" name="company_name" id="companyName" placeholder="Enter company name">
                      </div>
                      <div class="form-group">
                        <label for="stateOfFormation">State of Formation</label>
                        <input type="text" value="{{ old('state_of_formation', $report->state_of_formation ?? '') }}" class="form-control" name="state_of_formation" id="stateOfFormation" placeholder="Enter state of formation">
                      </div>

                      <div class="form-group">
                        <label for="formationDate">Date of Formation (mm/dd/yyyy)</label>
                        <input type="date" value="{{ old('formation_date', $report->formation_date ?? '') }}" class="form-control" name="formation_date" id="formationDate">
                      </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 class="form-group">
                        <label for="oldCompanyName">Old Company Name</label>
                        <input type="text" value="{{ old('old_company_name', $report->old_company_name ?? '') }}" class="form-control" name="old_company_name" id="oldCompanyName" placeholder="Enter old company name">
                      </div>
                    </div>


                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="entityType">Type of Entity</label>
                        <select class="form-control" name="entity_type" id="entityType">
                          <option value="Corporation" {{ old('entity_type', $report->entity_type ?? '') == 'Corporation' ? 'selected' : '' }}>Corporation</option>
                          <option value="S Corporation" {{ old('entity_type', $report->entity_type ?? '') == 'S Corporation' ? 'selected' : '' }}>S Corporation</option>
                          <option value="Partnership" {{ old('entity_type', $report->entity_type ?? '') == 'Partnership' ? 'selected' : '' }}>Partnership</option>
                          <option value="Single Member LLC" {{ old('entity_type', $report->entity_type ?? '') == 'Single Member LLC' ? 'selected' : '' }}>Single Member LLC</option>
                          <option value="Multi Member LLC" {{ old('entity_type', $report->entity_type ?? '') == 'Multi Member LLC' ? 'selected' : '' }}>Multi Member LLC</option>
                          <option value="Sole Proprietor" {{ old('entity_type', $report->entity_type ?? '') == 'Sole Proprietor' ? 'selected' : '' }}>Sole Proprietor</option>
                        </select>
                      </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="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 class="form-group">
                        <label for="newCompanyName">New Company Name</label>
                        <input type="text" value="{{ old('new_company_name', $report->new_company_name ?? '') }}" class="form-control" name="new_company_name" id="newCompanyName" placeholder="Enter new company name">
                      </div>

                    </div>
                  </div>

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



                  <h4>Shareholder/Officers/Members Information</h4>

                  <div class="row">
                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="shareholder1Name">Shareholder 1 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="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="shareholder1Fax">Fax</label>
                        <input type="text" value="{{ old('shareholder1_fax', $report->shareholder1_fax ?? '') }}" class="form-control" name="shareholder1_fax" id="shareholder1Fax" placeholder="(123) 456-7890">
                      </div>

                      <div class="form-group">
                        <label for="shareholder1Phone">Phone</label>
                        <input type="text" value="{{ old('shareholder1_phone', $report->shareholder1_phone ?? '') }}" class="form-control" name="shareholder1_phone" id="shareholder1Phone" 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>
                  <!-- Repeat for Shareholders 2 and 3 if needed -->

                  <h4>Credit Card Authorization</h4>
                  <div class="row">
                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="cardholderName">Name on the Credit Card</label>
                        <input type="text" value="{{ old('cardholder_name', $report->cardholder_name ?? '') }}" class="form-control" name="cardholder_name" id="cardholderName" placeholder="Enter name">
                      </div>

                      <div class="form-group">
                        <label for="cardExpiration">CC Expiration Date</label>
                        <input type="month" value="{{ old('card_expiration', $report->card_expiration ?? '') }}" class="form-control" name="card_expiration" id="cardExpiration">
                      </div>

                      <div class="form-group">
                        <label for="billingCityStateZip">City, State, Zip</label>
                        <input type="text" value="{{ old('billing_city_state_zip', $report->billing_city_state_zip ?? '') }}" class="form-control" name="billing_city_state_zip" id="billingCityStateZip" placeholder="Enter city, state, zip">
                      </div>
                    </div>


                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="cardNumber">Credit Card Number</label>
                        <input type="text" value="{{ old('card_number', $report->card_number ?? '') }}" class="form-control" name="card_number" id="cardNumber" placeholder="Enter card number">
                      </div>

                      <div class="form-group">
                        <label for="csvCode">Security (CSV) Code</label>
                        <input type="text" value="{{ old('csv_code', $report->csv_code ?? '') }}" class="form-control" name="csv_code" id="csvCode" placeholder="Enter CSV code">
                      </div>


                    </div>
                  </div>

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


                  <div class="form-check">
                    <input type="checkbox" {{ old('agreement_check', $report->agreement_check ?? false) ? 'checked' : '' }} class="form-check-input" value="1" name="agreement_check" id="agreementCheck">
                    <label class="form-check-label" for="agreementCheck">I authorize Incorp.COM to apply for Certificate of Amendment and agree to the terms.</label>
                  </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);
    });
  });
</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>