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NewAuthRegistration.html
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NewAuthRegistration.html
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<!DOCTYPE html>
<html lang="en-US">
<head>
<title>ILLiad - New Authenticated User Registration</title>
<#INCLUDE filename="include_head.html">
</head>
<body>
<#INCLUDE filename="include_header.html">
<#INCLUDE filename="include_menu.html">
<div class="container">
<main id="content" aria-label="Content">
<form action="illiad.dll" method="post" name="NewAuthRegistration">
<input type="hidden" name="ILLiadForm" value="NewAuthRegistration">
<input type="hidden" name="NotificationMethod" value="Electronic">
<input type="hidden" id="ArticleBillingCategory" name="ArticleBillingCategory" value="<#PARAM name='ArticleBillingCategory'>">
<input type="hidden" id="LoanBillingCategory" name="LoanBillingCategory" value="<#PARAM name='LoanBillingCategory'>">
<input type="hidden" name="DeliveryGroup" value="Hold for Pickup">
<input type="hidden" name="LoanDeliveryGroup" value="Hold for Pickup">
<input type="hidden" name="WebDeliveryGroup" value="Yes">
<#FORMSTATE>
<fieldset>
<h2 class="page-header">New Authenticated User Registration for ILLiad</h2>
<section name="user-info">
<h3 class="section-header">User Information</h3>
<div class="form-group col-md-5">
<label for="FirstName">
<span class="<#ERROR name='ERRORFirstName'>">
First Name
<span class="req">(required)</span>
</span>
</label>
<input type="text" class="form-control" name="FirstName" id="FirstName" value="<#PARAM name='FirstName'>" required>
</div>
<div class="form-group col-md-5">
<label for="LastName">
<span class="<#ERROR name='ERRORLastName'>">
Last Name
<span class="req">(required)</span>
</span>
</label>
<input type="text" class="form-control" name="LastName" id="LastName" value="<#PARAM name='LastName'>" required>
</div>
<div class="form-group col-md-5">
<label for="SSN">
<span class="<#ERROR name='ERRORSSN'>">
ID Number
<span class="req">(required)</span>
</span>
</label>
<input id="SSN" name="SSN" class="form-control" value="<#PARAM name='SSN'>" required>
</div>
<div class="form-group col-md-6">
<label for="EMailAddress">
<span class="<#ERROR name='ERROREMailAddress'>">
Email Address
<span class="req">(required)</span>
</span>
</label>
<input type="text" class="form-control" name="EMailAddress" id="EMailAddress" value="<#PARAM name='EMailAddress'>" required>
</div>
<div class="form-group col-md-5">
<label for="Phone">
<span class="field">
<span class="<#ERROR name='ERRORPhone'>">
Daytime Phone
<span class="req">(required)</span>
</span>
</span>
</label>
<input type="text" class="form-control" name="Phone" id="Phone" value="<#PARAM name='Phone'>" required>
</div>
<div class="form-group col-md-5">
<label for="MobilePhone">
<span class="field">
<span class="<#ERROR name='ERRORMobilePhone'>">
Mobile Phone
</span>
</span>
</label>
<input type="text" class="form-control" name="MobilePhone" id="MobilePhone" value="<#PARAM name='MobilePhone'>">
</div>
<div class="form-group col-md-5">
<label for="Department">
<span class="field">
<span class="<#ERROR name='ERRORDepartment'>">
Department
<span class="req">(required)</span>
</span>
</span>
<select id="Department" name="Department" size="1" class="custom-select mr-sm-2" required>
<#OPTION name="custom" groupname="Department" selectedValue="<#PARAM name='Department'>">
</select><br>
</label>
</div>
<div class="form-group col-md-5">
<label for="StatusGroup">
<span class="field">
<span class="<#ERROR name='ERRORStatus'>">
Status
<span class="req">(required)</span>
</span>
</span>
<select id="StatusGroup" name="StatusGroup" size="1" class="custom-select mr-sm-2" required>
<#OPTION name="custom" groupname="StatusGroup" selectedValue="<#PARAM name='StatusGroup'>">
</select>
<br>
</label>
</div>
<div class="form-group col-md-5">
<label for="NVTGC">
<span class="field">
<span class="<#ERROR name='ERRORNVTGC'>">
Delivery Location
</span>
</span>
<select id="NVTGC" name="NVTGC" size="1" class="custom-select mr-sm-2">
<#OPTION name="custom" groupname="NVTGC" selectedValue="<#PARAM name='NVTGC'>">
</select>
<br>
</label>
</div>
</section>
<section name="address-info">
<h3 class="section-header">Address Information</h3>
<div class="form-group col-md-6">
<label for="Address">
<span class="<#ERROR name='ERRORAddress'>">
Address Line 1
<span class="req">(required)</span>
</span>
</label>
<input type="text" class="form-control" name="Address" id="Address" value="<#PARAM name='Address'>" required>
</div>
<div class="form-group col-md-6">
<label for="Address2">
<span class="<#ERROR name='ERRORAddress2'>">
Address Line 2
</span>
</label>
<input type="text" class="form-control" name="Address2" id="Address2" value="<#PARAM name='Address2'>">
</div>
<div class="form-group col-md-4">
<label for="City">
<span class="<#ERROR name='ERRORCity'>">
Address City
<span class="req">(required)</span>
</span>
</label>
<input type="text" class="form-control" name="City" id="City" value="<#PARAM name='City'>" required>
</div>
<div class="form-group col-md-4">
<label for="State">
<span class="<#ERROR name='ERRORState'>">
Address State
<span class="req">(required)</span>
</span>
</label>
<select id="State" name="State" size="1" class="custom-select mr-sm-2" required>
<#OPTION name="custom" groupname="State" selectedValue="<#PARAM name='State'>">
</select><br>
</div>
<div class="form-group col-md-4">
<label for="Zip">
<span class="<#ERROR name='ERRORZip'>">
Address Zip
<span class="req">(required)</span>
</span>
</label>
<input type="text" class="form-control" name="Zip" id="Zip" value="<#PARAM name='Zip'>" required>
</div>
</section>
<!--
If this section is to be removed/unused, then remove the matching hidden inputs and the top of this page
<section name="delivery-method-info">
<h3>Delivery Methods</h3>
<div class="form-group col-md-5">
<label for="DeliveryGroup">
<span class="field">
<span class="<#ERROR name='ERRORDeliveryGroup'>">
Preferred Article Delivery Method
</span>
</span>
</label>
<select id="DeliveryGroup" name="DeliveryGroup" size="1" class="custom-select mr-sm-2" data-persistedValue="<#PARAM name='DeliveryGroup'>">
<option value="Hold for Pickup">Hold for Pickup</option>
<option value="Mail to Address">Mail to Address</option>
</select>
</div>
<div class="form-group col-md-5">
<label for="LoanDeliveryGroup">
<span class="field">
<span class="<#ERROR name='ERRORLoanDeliveryGroup'>">
Preferred Loan Delivery Method
</span>
</span>
</label>
<select id="LoanDeliveryGroup" name="LoanDeliveryGroup" size="1" class="custom-select mr-sm-2" data-persistedValue="<#PARAM name='LoanDeliveryGroup'>">
<option value="Hold for Pickup">Hold for Pickup</option>
<option value="Mail to Address">Mail to Address</option>
</select>
</div>
<div class="form-group col-md-5">
<label for="WebDeliveryGroup">
<span class="field">
<span class="<#ERROR name='ERRORWebDeliveryGroup'>">
Preferred Electronic Delivery if Possible (PDF file via web)
</span>
</span>
</label>
<select id="WebDeliveryGroup" name="WebDeliveryGroup" size="1" class="custom-select mr-sm-2" data-persistedValue="<#PARAM name='WebDeliveryGroup'>">
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</section>
-->
<button class="btn btn-primary btn-md" type="submit" name="SubmitButton" value="Submit Information">Submit Information</button>
<button class="btn btn-secondary btn-md" type="submit" name="SubmitButton" value="Cancel - Exit ILLiad System" formnovalidate>Cancel - Exit ILLiad System</button>
</fieldset>
</form>
</main>
<#INCLUDE filename="include_footer.html">
</div>
</body>
</html>