@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/फ्लॅट क्रमांक / <br> House/Flat 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>घर/इमारतीचे नाव / <br> House/Building 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>ओळ १ / <br> Line 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>ओळ २ / <br> Line 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="cat_name" id="cat_name"
                                                value="{{ !empty($data->cat_name) ? $data->cat_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="2026-06-09"
                                                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="2026-06-09"
                                                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('/') }}/TMC_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('/') }}/TMC_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')