@include('common.header')

<link rel="stylesheet" href="//code.jquery.com/ui/1.12.1/themes/base/jquery-ui.css">

<section class="content">
    <div class="body_scroll">
        <div class="block-header">
            <div class="row">
                <div class="col-lg-7 col-md-6 col-sm-12">
                    <h2>PET Application</h2>
                    <ul class="breadcrumb">
                        <li class="breadcrumb-item"><a href="{{ url('/admin/dashboard') }}"><i class="zmdi zmdi-home"></i> Home</a></li>
                        <!--<li class="breadcrumb-item"><a href="{{ url('/#') }}">PET Application</a></li>-->
                        <li class="breadcrumb-item active">PET Application</li>
                    </ul>
                    <button class="btn btn-primary btn-icon mobile_menu" type="button"><i class="zmdi zmdi-sort-amount-desc"></i></button>
                </div>
                
                <div class="col-lg-5 col-md-6 col-sm-12">
                    <button class="btn btn-primary btn-icon float-right right_icon_toggle_btn" type="button"><i class="zmdi zmdi-arrow-right"></i></button>
                </div>
            </div>
        </div>

        <div class="container-fluid">
            <!-- Vertical Layout -->
            <div class="row clearfix">
                <div class="col-lg-12 col-md-12 col-sm-12">
                    <div class="card">
                        <div class="body">
                            <form method="post" action="{{ url('/veterinary_reg_list/edit/store') }}" class="form-horizontal" enctype="multipart/form-data">
                                @csrf
                                
                                <input type="hidden" name="pet_user_id" id="pet_user_id" class="form-control " value="{{ $data->id }}">
                                
                                <section class="pt-3">
        						            							<div class="form-group row">
                                        <label class="col-sm-2 col-form-label"><strong>Category of Application / ( अर्जाचा प्रकार ) : &nbsp;<span class="text-danger">*</span> </strong></label>
                                        <div class="col-sm-2 col-md-2 ">
                                            <input class="form-control " name="category_appli_id" id="category_appli_id" value="{{ $category_appli_id }}" readonly>
                                        </div>
                                        
                                        <label class="col-sm-1"><strong>Ward / <br> ( प्रभाग ) : <span style="color:red;">*</span></strong></label>
                                        <div class="col-sm-3 col-md-3">
                                            <input class="form-control " name="ward_id" id="ward_id" value="{{ (!empty($data->ward_name)) ? $data->ward_name : '' }}" readonly>
                                        </div>
                                        
                                        <label class="col-sm-1"><strong>Department/ ( विभाग ) : <span style="color:red;">*</span></strong></label>
                                        <div class="col-sm-3 col-md-3">
                                            <input class="form-control " name="dept_id" id="dept_id" value="{{ (!empty($data->dept_name)) ? $data->dept_name : '' }}" readonly>
                                        </div>
                                    </div>
                                    
                                                                        <strong class="pb-1">Name of Applicant / ( अर्जदाराचे नाव ) : <span style="color:red;">*</span> </strong>
                                    <div class="form-group row">
                                        <!--<label class="col-sm-1"><strong>Title : <span style="color:red;">*</span></strong></label>-->
                                        <div class="col-sm-3 col-md-3 p-2">
                                            <input class="form-control " name="applicant_title_id" id="applicant_title_id" value="{{ $applicant_title_id }}" readonly>
                                        </div>
                                        
                                        
                                        <!--<label class="col-sm-1"><strong>First Name : <span style="color:red;">*</span></strong></label>-->
                                        <div class="col-sm-3 col-md-3 p-2">
                                            <input readonly class="form-control " name="applicant_fname" id="applicant_fname" value="{{ (!empty($data->applicant_fname)) ? $data->applicant_fname : '' }}" >
                                            
                                        </div>
                                        
                                        <!--<label class="col-sm-1"><strong>Middle Name : <span style="color:red;">*</span></strong></label>-->
                                        <div class="col-sm-3 col-md-3 p-2">
                                            <input readonly class="form-control " name="applicant_mname" id="applicant_mname" value="{{ (!empty($data->applicant_mname)) ? $data->applicant_mname : '' }}" >
                                            
                                        </div>
                                        
                                        <!--<label class="col-sm-1"><strong>Last Name : <span style="color:red;">*</span></strong></label>-->
                                        <div class="col-sm-3 col-md-3 p-2">
                                            <input readonly class="form-control " name="applicant_lname" id="applicant_lname" value="{{ (!empty($data->applicant_lname)) ? $data->applicant_lname : '' }}" >
                                            
                                        </div>
                                    </div>
                                    
                                                                        <strong class="pb-1">Name of Owner's / ( मालकाचे नाव ) : <span style="color:red;">*</span> </strong>
                                    <div class="form-group row">
                                        <!--<label class="col-sm-1"><strong>Title : <span style="color:red;">*</span></strong></label>-->
                                        <div class="col-sm-3 col-md-3 p-2">
                                            <input class="form-control " name="owner_title_id" id="owner_title_id" value="{{ $owner_title_id }}" readonly>
                                        </div>
                                        
                                        
                                        <!--<label class="col-sm-1"><strong>First Name : <span style="color:red;">*</span></strong></label>-->
                                        <div class="col-sm-3 col-md-3 p-2">
                                            <input readonly class="form-control " name="owner_fname" id="owner_fname" value="{{ (!empty($data->owner_fname)) ? $data->owner_fname : '' }}" >
                                            
                                        </div>
                                        
                                        <!--<label class="col-sm-1"><strong>Middle Name : <span style="color:red;">*</span></strong></label>-->
                                        <div class="col-sm-3 col-md-3 p-2">
                                            <input readonly class="form-control " name="owner_mname" id="owner_mname" value="{{ (!empty($data->owner_mname)) ? $data->owner_mname : '' }}" >
                                            
                                        </div>
                                        
                                        <!--<label class="col-sm-1"><strong>Last Name : <span style="color:red;">*</span></strong></label>-->
                                        <div class="col-sm-3 col-md-3 p-2">
                                            <input readonly class="form-control " name="owner_lname" id="owner_lname" value="{{ (!empty($data->owner_lname)) ? $data->owner_lname : '' }}" >
                                            
                                        </div>
                                    </div>
                                    
                                    <strong class="pt-2 text-danger">
                                        Residential Address of Owner's / ( मालकाचा निवासी पत्ता  )
                                    </strong>
                                    <hr>
                                        
                                    <div class="form-group row">
                                        <label class="col-sm-2"><strong>घर क्रमांक / <br> House Number  :  </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="house_number" id="house_number" value="{{ (!empty($data->house_number)) ? $data->house_number : ''  }}" readonly>
                                        </div>
                                        
                                        <label class="col-sm-2"><strong>घराचे नाव / <br> House Name  : </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="house_name" id="house_name" value="{{ (!empty($data->house_name)) ? $data->house_name : ''  }}" readonly>
                                        </div>
                                    </div>
                                
                                    <div class="form-group row">
                                        <label class="col-sm-2"><strong>रस्ता १ / <br> Street 1 : </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="street_1" id="street_1" value="{{ (!empty($data->street_1)) ? $data->street_1 : ''  }}" readonly>
                                        </div>
                                        
                                        <label class="col-sm-2"><strong>रस्ता 2 / <br> Street 2  : </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="street_2" id="street_2" value="{{ (!empty($data->street_2)) ? $data->street_2 : ''  }}" readonly>
                                        </div>
                                    </div>
                                
                                    <div class="form-group row">
                                        <label class="col-sm-2"><strong>क्षेत्र १ / <br> Area 1 : </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="area_1" id="area_1" value="{{ (!empty($data->area_1)) ? $data->area_1 : ''  }}" readonly>
                                        </div>
                                        
                                        <label class="col-sm-2"><strong>क्षेत्र 2 / <br> Area 2  : </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="area_2" id="area_2" value="{{ (!empty($data->area_2)) ? $data->area_2 : ''  }}" readonly>
                                        </div>
                                    </div>
                                
                                    <div class="form-group row">
                                                                                
                                        <label class="col-sm-2"><strong>देश / <br> Country : </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="country_id" id="country_id" value="{{ $country_id }}" readonly>
                                        </div>
                                        
                                                                                <label class="col-sm-2"><strong>राज्य / <br> State : </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="state_id" id="state_id" value="{{ $state_id }}" readonly>
                                        </div>
                                    </div>
                                    
                                    <div class="form-group row">
                                        <label class="col-sm-2"><strong>जिल्हा / <br> District : </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="district_id" id="district_id" value="{{ (!empty($data->dist_name)) ? $data->dist_name : ''  }}" readonly>
                                        </div>
                                        
                                        <label class="col-sm-2"><strong>तालुका / <br> Taluka  : </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="taluka_id" id="taluka_id" value="{{ (!empty($data->taluka_name)) ? $data->taluka_name : ''  }}" readonly>
                                        </div>
                                    </div>
                                
                                    <div class="form-group row">
                                        <label class="col-sm-2"><strong>पिनकोड / <br> Zip Code : </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="zipcode" id="zipcode" value="{{ (!empty($data->zipcode)) ? $data->zipcode : ''  }}" readonly>
                                        </div>
                                        
                                        <label class="col-sm-2"><strong>जीएसटी क्रमांक / <br> GST Number  :  </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="gst_number" id="gst_number" value="{{ (!empty($data->gst_number)) ? $data->gst_number : ''  }}" readonly>
                                        </div>
                                    </div>
                                
                                    <div class="form-group row">
                                        <label class="col-sm-2"><strong>मोबाईल नंबर / <br> Mobile Number : </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="mobile_number" id="mobile_number" value="{{ (!empty($data->mobile_number)) ? $data->mobile_number : ''  }}" readonly>
                                        </div>
                                        
                                        <label class="col-sm-2"><strong>ई - मेल आयडी / Email Id  :  <br><span class="text-danger"> (Receipt and Certificate will be sent on this Email ID)</span>  </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="email" id="email" value="{{ (!empty($data->email)) ? $data->email : ''  }}" readonly>
                                        </div>
                                    </div>
                                
                                    <div class="form-group row">
                                        <label class="col-sm-2"><strong>आधार क्रमांक / <br> Aadhar Number : </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="aadhar_number" id="aadhar_number" value="{{ (!empty($data->aadhar_number)) ? $data->aadhar_number : ''  }}" readonly>
                                        </div>
                                        
                                        <label class="col-sm-2"><strong>पॅन कार्ड / <br> PAN Card  :  </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="pan_number" id="pan_number" value="{{ (!empty($data->pan_number)) ? $data->pan_number : ''  }}" readonly>
                                        </div>
                                    </div>
                                
                                    <div class="form-group row">
                                        <label class="col-sm-2"><strong>मतदार कार्ड क्रमांक / <br> Voter’s Card Number : </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="voter_card_no" id="voter_card_no" value="{{ (!empty($data->voter_card_no)) ? $data->voter_card_no : ''  }}" readonly>
                                        </div>
                                        
                                        <label class="col-sm-2"><strong>संस्थेचे नाव / Name of the Firm  :  </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="name_of_firm" id="name_of_firm" value="{{ (!empty($data->name_of_firm)) ? $data->name_of_firm : ''  }}" readonly>
                                        </div>
                                    </div>
                                    
                                    <strong class="pt-2 text-danger text-justify">
                                        Note : <br>
                                        1. Please fill all the Dog details below, Since and Vaccination Date should be in mm/dd/yyyy format only Ex. 01/20/2018 .<br>
                                        2. Select Others in Breed and enter details if Dog Breed not found if drop down .<br>
                                        3. Vaccination Certificate of size upto 2 MB to be Uploaded as attachment .
                                    </strong>
                                    <hr>
                                    
                                    <strong class="pt-2 text-danger text-justify">
                                        नोंद : <br>
                                        1. कृपया खाली सर्व कुत्र्याचे तपशील भरा, पासून आणि लसीकरणाची तारीख फक्त mm/dd/yyyy स्वरूपात असावी उदा. 01/20/2018 .<br>
                                        2. जातीतील इतर निवडा आणि ड्रॉप डाउन असल्यास डॉग ब्रीड आढळले नसल्यास तपशील प्रविष्ट करा.<br>
                                        3. संलग्नक म्हणून अपलोड करण्यासाठी 2 MB पर्यंत आकाराचे लसीकरण प्रमाणपत्र.
                                    </strong>
                                    <hr>
                                    
                                    <div class="form-group row">
                                        <label class="col-sm-2"><strong>कुत्र्याचे नाव / <br> Dog Name : </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="dog_name" id="dog_name" value="{{ (!empty($data->dog_name)) ? $data->dog_name : ''  }}" readonly>
                                        </div>
                                        
                                                                                <label class="col-sm-2"><strong>लिंग / <br> Sex  :  </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="sex_id" id="sex_id" value="{{ $sex_id }}" readonly>
                                        </div>
                                    </div>
                                    
                                    <div class="form-group row">
                                        <label class="col-sm-2"><strong>ओळख चिन्ह / <br> Identification Mark : </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="identification_mark" id="identification_mark" value="{{ (!empty($data->identification_mark)) ? $data->identification_mark : ''  }}" readonly>
                                        </div>
                                        
                                        <label class="col-sm-2"><strong>जाती / <br> Breed :  </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="breed_id" id="breed_id" value="{{ (!empty($data->breeds_name)) ? $data->breeds_name : ''  }}" readonly>
                                        </div>
                                    </div>
                                    
                                    <div class="form-group row">
                                        <label class="col-sm-2"><strong>इतर जाती / <br> Other Breed : </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="other_breed" id="other_breed" value="{{ (!empty($data->other_breed)) ? $data->other_breed : ''  }}" readonly>
                                        </div>
                                        
                                        <label class="col-sm-2"><strong>रंग /<br> Colour  : </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="colour" id="colour" value="{{ (!empty($data->colour)) ? $data->colour : ''  }}" readonly>
                                        </div>
                                    </div>
                                    
                                    <div class="form-group row">
                                        <label class="col-sm-2"><strong>पशुवैद्यकीय डॉक्टरांचे नाव / <br> Veterinary Doctor Name : </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="veterinary_doctor_name" id="veterinary_doctor_name" value="{{ (!empty($data->veterinary_doctor_name)) ? $data->veterinary_doctor_name : ''  }}" readonly>
                                        </div>
                                        
                                        <label class="col-sm-2"><strong>पशुवैद्यकीय डॉक्टरांचा MSVC/VCI नोंदणी क्रमांक / <br> Veterinary doctor’s MSVC/VCI registration number  : </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input class="form-control " name="veterinary_doctor_msvc_no" id="veterinary_doctor_msvc_no" value="{{ (!empty($data->veterinary_doctor_msvc_no)) ? $data->veterinary_doctor_msvc_no : ''  }}" readonly>
                                        </div>
                                    </div>
                                    
                                    <hr>
                                    <div class="form-group row">
                                        <label class="col-sm-2"><strong> Date of Rabies Vaccination (DD/MM/YYYY) / <br> (रेबीज लसीकरणाची तारीख (DD/MM/YYYY) ) : <span style="color:red;">*</span></strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input type="text" name="date_of_rabies_vaccination" id="date_of_rabies_vaccination" class="form-control @error('date_of_rabies_vaccination') is-invalid @enderror" max="2026-04-16" value="{{ (!empty($data->date_of_rabies_vaccination)) ? $data->date_of_rabies_vaccination : ''  }}" placeholder="DD/MM/YYYY">
                                            @error('date_of_rabies_vaccination')
                                                <span class="invalid-feedback" role="alert">
                                                    <strong>{{ $message }}</strong>
                                                </span>
                                            @enderror
                                        </div>
                                        
                                        <label class="col-sm-2"><strong>Date of Leptospirosis Vaccination (DD/MM/YYYY) / <br> (लेप्टोस्पायरोसिस लसीकरणाची तारीख (DD/MM/YYYY) (DD/MM/YYYY)) : <span style="color:red;">*</span></strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input type="text" name="date_of_leptospirosis_vaccination" id="date_of_leptospirosis_vaccination" class="form-control @error('date_of_leptospirosis_vaccination') is-invalid @enderror" max="2026-04-16" value="{{ (!empty($data->date_of_leptospirosis_vaccination)) ? $data->date_of_leptospirosis_vaccination : ''  }}" placeholder="DD/MM/YYYY">
                                            @error('date_of_leptospirosis_vaccination')
                                                <span class="invalid-feedback" role="alert">
                                                    <strong>{{ $message }}</strong>
                                                </span>
                                            @enderror
                                        </div>
                                    </div>
                                    
                                    
                                    
                                    <div class="form-group row">
                                        <label class="col-sm-2"><strong>Upload Rabies Vaccination certificate / <br>( रेबीज लसीकरण प्रमाणपत्र अपलोड करा ) : <span style="color:red;">*</span> </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input type="file" name="rabies_vaccination_certificate_doc" id="rabies_vaccination_certificate_doc"  class="form-control @error('rabies_vaccination_certificate_doc') is-invalid @enderror" value="{{ (!empty($data->rabies_vaccination_certificate_doc)) ? $data->rabies_vaccination_certificate_doc : ''  }}" accept=".jpg, .jpeg, .png, .pdf">
                                            <small class="text-secondary text-justify "> Note : The file should be less than 2MB .</small>
                                            <br>
                                            <small class="text-secondary text-justify "> Note : Only files in .jpg, .jpeg, .png, .pdf format can be uploaded .</small>
                                            <br>
                                            @error('rabies_vaccination_certificate_doc')
                                                <span class="invalid-feedback" role="alert">
                                                    <strong>{{ $message }}</strong>
                                                </span>
                                            @enderror
                                            <br>
                                            @if(!empty($data->rabies_vaccination_certificate_doc))
                                                <a href="{{ url('/') }}/PMC_PET_Registration/rabies_vaccination_certificate_doc/{{ $data->rabies_vaccination_certificate_doc }}" target="_blank" class="btn btn-info btn-sm text-light">
                                                    &nbsp;&nbsp;View Document&nbsp;&nbsp;
                                                </a>
                                            @endif
                                        </div>
                                        
                                        <label class="col-sm-2"><strong>Upload Vaccination certificate of Leptospirosis / <br> ( लेप्टोस्पायरोसिसचे लसीकरण प्रमाणपत्र अपलोड करा ) : <span style="color:red;">*</span> </strong></label>
                                        <div class="col-sm-4 col-md-4 p-2">
                                            <input type="file" name="vaccination_certificate_of_Lepto_doc" id="vaccination_certificate_of_Lepto_doc" class="form-control @error('vaccination_certificate_of_Lepto_doc') is-invalid @enderror" value="{{ (!empty($data->vaccination_certificate_of_Lepto_doc)) ? $data->vaccination_certificate_of_Lepto_doc : ''  }}" accept=".jpg, .jpeg, .png, .pdf">
                                            <small class="text-secondary text-justify "> Note : The file should be less than 2MB .</small>
                                            <br>
                                            <small class="text-secondary text-justify "> Note : Only files in .jpg, .jpeg, .png, .pdf format can be uploaded .</small>
                                            <br>
                                            @error('vaccination_certificate_of_Lepto_doc')
                                                <span class="invalid-feedback" role="alert">
                                                    <strong>{{ $message }}</strong>
                                                </span>
                                            @enderror
                                            <br>
                                            @if(!empty($data->vaccination_certificate_of_Lepto_doc))
                                                <a href="{{ url('/') }}/PMC_PET_Registration/vaccination_certificate_of_Lepto_doc/{{ $data->vaccination_certificate_of_Lepto_doc }}" target="_blank" class="btn btn-info btn-sm text-light">
                                                    &nbsp;&nbsp;View Document&nbsp;&nbsp;
                                                </a>
                                            @endif
                                        </div>
                                    </div>
                                            
                                    <div class="form-group row mt-4">
                                        <label class="col-md-3"></label>
                                        <div class="col-md-9" style="display: flex; justify-content: flex-end;">
                                            <a href="{{ url('/veterinary_reg_list') }}" class="btn btn-danger btn-lg">Cancel</a>&nbsp;&nbsp;
                                            <button type="submit" class="btn btn-success btn-lg">Submit</button>
                                        </div>
                                    </div>
                                    
        						</section>
                            </form>
                        </div>
                    </div>
                </div>
            </div>
        </div>
    </div>
</section>



@include('common.footer')