<!DOCTYPE html>
<html>
<head>
    <title>Ringba Request</title>
    <link href="https://cdn.jsdelivr.net/npm/bootstrap@5.3.2/dist/css/bootstrap.min.css" rel="stylesheet">
</head>
<body class="p-5">
<div class="container">
    <h3 class="mb-4">Send Ringba Request</h3>

    <?php if(session('success')): ?>
        <div class="alert alert-success"><?php echo e(session('success')); ?></div>
    <?php endif; ?>

    <?php if(session('error')): ?>
        <div class="alert alert-danger"><?php echo e(session('error')); ?></div>
    <?php endif; ?>

    <form action="<?php echo e(route('mva')); ?>" method="POST">
        <?php echo csrf_field(); ?>
        <div class="mb-3">
            <label class="form-label">CID</label>
            <input type="text" name="CID" class="form-control" placeholder="Enter CID" required>
        </div>
        <div class="mb-3">
            <label class="form-label">Zip Code</label>
            <input type="text" name="ZipCode" class="form-control" placeholder="Enter Zip Code" required>
        </div>
        <div class="mb-3">
            <label class="form-label">First Name</label>
            <input type="text" name="firstname" class="form-control" placeholder="Enter First Name" required>
        </div>
        <div class="mb-3">
            <label class="form-label">Last Name</label>
            <input type="text" name="lastname" class="form-control" placeholder="Enter Last Name" required>
        </div>
        <div class="mb-3">
            <label class="form-label">Email</label>
            <input type="email" name="email" class="form-control" placeholder="Enter Email" required>
        </div>
        <div class="mb-3">
            <label class="form-label">Trusted ID</label>
            <input type="url" name="trusted_id" class="form-control" placeholder="Enter TrustedForm ID URL">
        </div>
        <div class="mb-3">
            <label class="form-label">State</label>
            <input type="text" name="state" class="form-control" placeholder="Enter State" required>
        </div>
        <div class="form-check mb-3">
            <input type="checkbox" name="exposeCallerId" class="form-check-input" value="yes" checked>
            <label class="form-check-label">Expose Caller ID</label>
        </div>
        <button type="submit" class="btn btn-primary">Send Request</button>
    </form>
</div>
</body>
</html>
<?php /**PATH /home/u180427332/domains/lime-stinkbug-754807.hostingersite.com/public_html/mulikat/resources/views/rtbmv.blade.php ENDPATH**/ ?>