37 lines
1.4 KiB
PHP
37 lines
1.4 KiB
PHP
<div class='page-box-center'>
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<h2>Passport and birthdate information</h2>
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<form action="passportinfo.php" method="post" accept-charset="utf-8" id='passportinfo_form'>
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<p>Please fill out each field.</p>
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<fieldset class='person'>
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<legend>Passport Information</legend>
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<p class='field'>
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Name as on passport
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<input type="text" size="30" name="passport_name[]" id="passport_name" />
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</p>
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<p class='field'>
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Birthdate (mm/dd/yyyy)
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<input type="text" size="10" name="passport_birthdate[]" id="birthdate" />
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</p>
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<p class='field'>
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Passport number
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<input type="text" size="30" name="passport_number[]" id="passport_number" />
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</p>
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<p class='field'>
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Passport expiration date
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<input type="text" size="10" name="passport_expirationdate[]" id="passport_expirationdate" />
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</p>
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<p class='field'>
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Country of passport issuance
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<input type="text" size="30" name="passport_country[]" id="passport_country" />
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</p>
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<p><input type="button" name="delete_person" value="- Delete person" class='delete_person' disabled='disabled'/></p>
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</fieldset>
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<p>
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<input type='button' id='add_person' name='add_person' value='+ Add a person'/>
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</p>
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<p class='field'>
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<input type="submit" value="Submit Information"/>
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</p>
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</form>
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</div> |