@extends('website.layouts.app')

@section('content')
    <div class="container">
        <div class="pb-5">
            <div class="back_page">
                <i class="fa-solid fa-arrow-left"></i>
                <a href="{{ route('customer.dashboard') }}">Back to dashboard</a>
            </div>

            <div class="mandatory-form-container">
                <div class="card">
                    <div class="card-header">
                        <div class="h5 mb-0">Nominee Registration</div>
                    </div>
                    <div class="card-body">
                        <form action="{{ route('form17.saveNomineeRegistration') }}" class="form-horizontal" method="POST">
                            @csrf
                            <div class="form-group">
                                <div class="row">
                                    <div class="col-md-4">
                                        <label for="name" class="form-label">Name <span
                                                class="text-danger">*</span></label>
                                    </div>
                                    <div class="col-md-4">
                                        <input type="text" name="name" id="name"
                                            class="form-control @error('name') is-invalid @enderror"
                                            placeholder="Enter full name" value="{{ old('name', $custNomineeRegDtls['name']) }}" required>
                                        @error('name')
                                            <div class="invalid-feedback">{{ $message }}</div>
                                        @enderror
                                    </div>
                                </div>
                            </div>
                            <div class="form-group">
                                <div class="row">
                                    <div class="col-md-4">
                                        <label for="father_husband_name" class="form-label">Father / Husband Name <span
                                                class="text-danger">*</span></label>
                                    </div>
                                    <div class="col-md-4">
                                        <div class="row">
                                            <div class="col-md-4">
                                                <select name="son_wife_of" id="son_wife_of" class="form-select">
                                                    <option value="son_of" {{ old('son_wife_of', $custNomineeRegDtls['son_wife_of']) == 'son_of' ? 'selected' : '' }}>Son of</option>
                                                    <option value="wife_of" {{ old('son_wife_of', $custNomineeRegDtls['son_wife_of']) == 'wife_of' ? 'selected' : '' }}>Wife of</option>
                                                </select>
                                                @error('son_wife_of')
                                                    <div class="invalid-feedback">{{ $message }}</div>
                                                @enderror
                                            </div>
                                            <div class="col-md-8">
                                                <input type="text" name="father_husband_name" id="father_husband_name"
                                                    class="form-control @error('father_husband_name') is-invalid @enderror"
                                                    placeholder="Enter father/husband name" value="{{ old('father_husband_name', $custNomineeRegDtls['father_husband_name']) }}" required>
                                                @error('father_husband_name')
                                                    <div class="invalid-feedback">{{ $message }}</div>
                                                @enderror
                                            </div>
                                        </div>

                                    </div>
                                </div>
                            </div>
                            <div class="form-group">
                                <div class="row">
                                    <div class="col-md-4">
                                        <label for="member_no" class="form-label">Member Number <span class="text-danger">*</span></label>
                                    </div>
                                    <div class="col-md-4">
                                        <input type="text" name="member_no" id="member_no"
                                            class="form-control @error('member_no') is-invalid @enderror"
                                            placeholder="Enter member no" value="{{ old('member_no', $custNomineeRegDtls['member_no']) }}" required>
                                        @error('member_no')
                                            <div class="invalid-feedback">{{ $message }}</div>
                                        @enderror
                                    </div>
                                </div>
                            </div>
                            <div class="form-group">
                                <div class="row">
                                    <div class="col-md-4">
                                        <label for="location" class="form-label">Place of Registration <span class="text-danger">*</span></label>
                                    </div>
                                    <div class="col-md-4">
                                        <input type="text" name="location" id="location"
                                            class="form-control @error('location') is-invalid @enderror"
                                            placeholder="Enter state" value="{{ old('location', $custNomineeRegDtls['location']) }}" required>
                                        @error('location')
                                            <div class="invalid-feedback">{{ $message }}</div>
                                        @enderror
                                    </div>
                                </div>
                            </div>
                            <div class="seperator"></div>
                            <div class="form-group">
                                <div class="row">
                                    <div class="col-md-4">
                                        <label for="nominee_name" class="form-label">Name of the Nominee <span class="text-danger">*</span></label>
                                    </div>
                                    <div class="col-md-4">
                                        <input type="text" name="nominee_name" id="nominee_name"
                                            class="form-control @error('nominee_name') is-invalid @enderror"
                                            placeholder="Enter nominee name" value="{{ old('nominee_name', $custNomineeDtls['nominee_name']) }}" required>
                                        @error('nominee_name')
                                            <div class="invalid-feedback">{{ $message }}</div>
                                        @enderror
                                    </div>
                                </div>
                            </div>
                            <div class="form-group">
                                <div class="row">
                                    <div class="col-md-4">
                                        <label for="nominee_address" class="form-label">Address of the nominee <span class="text-danger">*</span></label>
                                    </div>
                                    <div class="col-md-4">
                                        <input type="text" name="nominee_address" id="nominee_address"
                                            class="form-control @error('nominee_address') is-invalid @enderror"
                                            placeholder="Enter nominee address" value="{{ old('nominee_address', $custNomineeDtls['nominee_address']) }}" required>
                                        @error('nominee_address')
                                            <div class="invalid-feedback">{{ $message }}</div>
                                        @enderror
                                    </div>
                                </div>
                            </div>
                            <div class="form-group">
                                <div class="row">
                                    <div class="col-md-4">
                                        <label for="relationship_with_member" class="form-label">Relationship with the member <span class="text-danger">*</span></label>
                                    </div>
                                    <div class="col-md-4">
                                        <input type="text" name="relationship_with_member" id="relationship_with_member"
                                            class="form-control @error('relationship_with_member') is-invalid @enderror"
                                            placeholder="Enter relationship" value="{{ old('relationship_with_member', $custNomineeDtls['relationship_with_member']) }}" required>
                                        @error('relationship_with_member')
                                            <div class="invalid-feedback">{{ $message }}</div>
                                        @enderror
                                    </div>
                                </div>
                            </div>
                            <div class="form-group">
                                <div class="row">
                                    <div class="col-md-4">
                                        <label for="nomination_expiry" class="form-label">Contingencies on the happening of which nomination shall become invalid <span class="text-danger">*</span></label>
                                    </div>
                                    <div class="col-md-4">
                                        <input type="date" name="nomination_expiry" id="nomination_expiry"
                                            class="form-control @error('nomination_expiry') is-invalid @enderror"
                                            placeholder="dd/mm/yyyy" value="{{ old('nomination_expiry', $custNomineeDtls['nomination_expiry']) }}" required>
                                        @error('nomination_expiry')
                                            <div class="invalid-feedback">{{ $message }}</div>
                                        @enderror
                                    </div>
                                </div>
                            </div>
                            <div class="form-group">
                                <div class="row">
                                    <div class="col-md-4">
                                        <label for="additional_info" class="form-label">Name, address and relationship of the person if any to whom the right of the nominee shall pass in the event of his predecessing the member <span class="text-danger">*</span></label>
                                    </div>
                                    <div class="col-md-4">
                                        <textarea name="additional_info" id="additional_info"
                                            class="form-control @error('additional_info') is-invalid @enderror"
                                            placeholder="..." required>{{ old('additional_info', $custNomineeDtls['additional_info']) }}</textarea>
                                        @error('additional_info')
                                            <div class="invalid-feedback">{{ $message }}</div>
                                        @enderror
                                    </div>
                                </div>
                            </div>

                            <div class="form-group">
                                <div class="row">
                                    <div class="col-md-4">&nbsp;</div>
                                    <div class="col-md-4">
                                        <div class="text-center">
                                            <button type="submit" class="btn btn-primary">Submit</button>
                                            <a href="{{ route('customer.dashboard') }}" class="btn btn-danger ms-2">Cancel</a>
                                        </div>
                                    </div>
                                </div>

                            </div>
                        </form>
                    </div>
                </div>
            </div>
        </div>
    </div>
@endsection