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<?php include('includes/fpdf.php'); function inputfield($field,$id,$label,$missing,$warning) { $a= "<label for=\"$field\">$label"; if (isset($missing) && in_array($id,$missing)) { $a.="<span class=\"warning\">$warning</span>"; } $a.="</label>"; $a.= "<input name=\"$field\" id=\"$id\" class=\"formbox\" type=\"text\""; if (isset($missing)) { $a.=" value=\"".$_POST["id"]."\""; } $a.=">"; return $a; } ?>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" />
<link rel="stylesheet" type="text/css" href="CSS/main.css" /><title>Schedule Enrollments</title>

<?php /*if (function_exists('nukeMagicQuotes')) { nukeMagicQuotes(); }*/ if (array_key_exists('send', $_POST)) { $expected = array ('name','state','county','address','birthdate','birthplace','mom','dad','birthaddress','nickname','social'); $required = array ('name','state','county','address','birthdate','birthplace','mom','dad'); $missing = array(); // process the $_POST variables foreach ($_POST as $key => $value) { // assign to temporary variable and strip whitespace if not an array $temp = is_array($value) ? $value : trim($value); // if empty and required, add to $missing array if (empty($temp) && in_array($key, $required)) { array_push($missing, $key); } // otherwise, assign to a variable of the same name as $key elseif (in_array($key, $expected)) { ${$key} = $temp; } } if (empty($missing)) { $pdf=new FPDF(); $pdf->AddPage(); $pdf->SetFont('Times','B',16); $pdf->Cell(0,10,'AFFIDAVIT OF IDENTITY',0,0,'C'); $pdf->Ln(10); $pdf->SetFont('Times','',12); $pdf->Cell(0,10,'STATE OF '.$state.' COUNTY OF '.$county,0,0,'C'); $pdf->Ln(10); $pdf->Cell(0,10,'I, '.$name.', being duly sworn, and under penalties of perjury, state that:'); $pdf->Ln(5); $pdf->Cell(0,10,'I reside at '.$address); $pdf->Ln(5); $pdf->Cell(0,10,'I was born on the date '.$birthdate.' at '.$birthplace); $pdf->Ln(5); $pdf->Cell(0,10,'The name given to me at my birth was '.$name); $pdf->Ln(5); $pdf->Cell(0,10,'The names of my parents at the time of my birth were '.$mom.' and '.$dad); if($birthaddress) { $pdf->Ln(5); $pdf->Cell(0,10,'My address at the time of my birth was '.$birthaddress); } if($nickname) { $pdf->Ln(5); $pdf->Cell(0,10,'I am also known by others as '.$nickname); } if($social) { $pdf->Ln(5); $pdf->Cell(0,10,'My soial security number is '.$social); } $pdf->Ln(5); $pdf->Cell(0,10,'The biometric information which is obtained today by __________________ and which further identifies me is'); $pdf->Ln(5); $pdf->Cell(0,10,'to be made part of this record.'); $pdf->Ln(5); $pdf->Cell(0,10,'I am responsible for determining under what circumstances the information in this record is to be disclosed, and to'); $pdf->Ln(5); $pdf->Cell(0,10,'whom it will be disclosed, as specified in my Disclosure Practice Statement'); $pdf->Ln(15); $pdf->Cell(0,10,'_______________________________________ ______________'); $pdf->Ln(5); $pdf->Cell(0,10,'Signature Date'); $pdf->Ln(15); $pdf->SetFont('Times','B',16); $pdf->Cell(0,10,'Jurat',0,0,'C'); $pdf->SetFont('Times','',12); $pdf->Ln(10); $pdf->Cell(0,10,'Before me, a duly commissioned Notary Public within and for the state of '.$state.' and county of '.$county.' aforesaid, personally appeared'); $pdf->Ln(5); $pdf->Cell(0,10,$name.' who, after being dulysworn as required by law, deposes and says the foregoing and'); $pdf->Ln(5); $pdf->Cell(80,10,'that this affidavit is made for the purpose of establishing [his/her] indentity for purposes to be determined by'); $pdf->Ln(5); $pdf->Cell(0,10,'[himself/herself]'); $pdf->Ln(10); $pdf->Cell(0,10,'Subscribed and sworn to before me this ____ day of ________, 20___ my commission expires'); $pdf->Ln(15); $pdf->Cell(0,10,'_________________________'); $pdf->Ln(15); $pdf->Cell(0,10,'NOTARY PUBLIC'); $pdf->Ln(5); $pdf->Cell(0,10,'Copyright 2001-2008 Village Inc. All rights reserved.'); $pdf->Output('/home/brandon/created/test.pdf'); } unset($missing); $pdfmade = true; } ?>
</head>

<body>
<h1>Schedule One Face-To-Face Enrollment</h1>
<h2><br />
If your digital and physical assets and spaces call for the
most reliable identities of the people who will access them,
then you've come to the right place.
<br />
<br />
<span style="font-weight: normal;">
Your face-to-face
enrollment is a Notarial process, meaning
that you'll have the benefit of the skills of an individual who is
legally required to know how to perform identity verification, and who
as a public official applies the authority of the state to the
enrollment document. Among other things this places you, the enrollee,
under
penalty of perjury for claims made in the oath and accompanying
affidavit.
<b>It is in your interest to ensure that you do not knowingly
enter any false information in this form.</b>
</span><br />
<br />
First, let us know when and where you would like the
enrollment to take place:
<br />
<br />
<form id="timeandplace" method="post" action="">
<p><?php echo inputfield("where","state","City and State where enrollment session is desired:",$missing,"Please enter the name of the location where an enrollment session is desired"); echo "</p><p>"; echo inputfield("when","when","What time of day, or time range, is best:",$missing,"Please enter the date on which you would like to have your enrollment session"); echo "</p><p>"; echo inputfield("phone","phone","Telephone number at which we can contact you:",$missing,"Please give us a phone number so we can make this appointment"); echo "</p><p>"; echo inputfield("email","email","Email address:",$missing,"Please give us your email address for further contact"); ?>
</p>
<p><input name="send" id="send" value="Schedule enrollment session" type="submit" />
</p>
</form>
<br />
<br />
</h2>
<h1>Affidavit Form</h1>
<h2>Complete this form to generate the affidavit that will be
used at your enrollment session.</h2>
<div id="wrapper">
<?php if ($_POST && isset($missing)) { ?>
<p class="warning">Please complete the missing item(s)
indicated.</p>
<?php } elseif ($_POST && $pdfmade) { ?>
<p><strong>Your affidavit has been created.</strong></p>
<?php include('includes/mail.inc.php'); } ?>
<form id="feedback" method="post" action="">
<p><?php echo inputfield("name","name","Full Name:",$missing,"Please enter your name"); echo "</p><p>"; echo inputfield("state","state","City and state to be enrolled in:",$missing,"Please enter the state you will be enrolling in"); echo "</p><p>"; echo inputfield("county","county","County to be enrolled in:",$missing,"Please enter the county you will be enrolling in"); echo "</p><p>"; echo inputfield("address","address","Home Address:",$missing,"Please enter your address"); echo "</p><p>"; echo inputfield("birthdate","birthdate","Birthdate:","Please enter your birthdate"); echo "</p><p>"; echo inputfield("birthplace","birthplace","Place of birth (city and state):",$missing,"Please enter your birthplace"); echo "</p><p>"; echo inputfield("mom","mom","Mother's full name:",$missing,"Please enter your mother's full name"); echo "</p><p>"; echo inputfield("dad","dad","Father's full name:",$missing,"Please enter your father's full name"); echo "</p><p>"; echo inputfield("license","license","Driver's license number",$missing,"We need some credential which asserts your identity"); echo "</p><p>"; echo inputfield("licensestate","licensestate","State issuing driver's license",$missing,""); echo "</p><p>"; echo "If you do not have a driver's license, then please give us at least one of these credentials:"; echo "</p><p>"; echo inputfield("passport","passport","Passport",$missing,""); echo "</p><p>"; echo inputfield("military","military","Military ID",$missing,""); echo "</p><p>"; echo inputfield("issued","issued","Date Issued:",$missing,""); echo "</p><p>"; echo inputfield("expires","expires","Date of Expiration:",$missing,""); echo "</p><p>"; echo inputfield("eyes","eyes","Eye Color:",$missing,""); echo "</p><p>"; echo inputfield("height","heigher","Height:",$missing,""); echo "</p><p>"; echo inputfield("race","race","Race:",$missing,""); echo "</p><p>"; echo "Optional Items"; echo "</p><p>"; echo inputfield("birthaddress","birthaddress","(optional) Address at time of birth:",$missing,"Please enter your address at the time you were born"); echo "</p><P>"; echo inputfield("nickname","nickname","(optional) Aliases, Nicknames:",$missing,"Please enter all of your aliases"); echo "</p><p>"; echo inputfield("social","social","(optional) Social Security number:",$missing,"Please enter your social security number"); ?>
</p>
<p>
<input name="send" id="send" value="Generate and send affidavit" type="submit" /></p>
</form>
</div>
</body></html>