@extends('layouts.app')
@section('css')
<style>
   .m-portlet__head-text{
   display: table-cell;
   vertical-align: middle;
   font-size: 1.3rem;
   font-weight: 500;
   font-family: Roboto;
   }
   .m-form .m-form__section.m-form__section--first, .m-form .m-form__section:first-child {
   margin-top: 40px!important;
   }
   .m-form.m-form--group-seperator-dashed .m-form__group {
   border-bottom: 0px!important;
   }
   .form-control{
   border: 1px solid #E6E7E8!important;
   overflow: hidden!important;
   border-radius: .40rem!important;
   font-family: sans-serif,Arial!important; 
   color: #575962!important;  
   font-size: 1rem!important;
   line-height: 1.25!important;
   background-color: #fff!important;
   }
   .m-form .m-form__heading .m-form__heading-title {
   color: #716aca;
   font-weight: 500;
   font-size: 1.3rem;
   }
   .form-control:focus,
   .form-control:active{
   border-color: #3273dc!important;;
   box-shadow: 0 0 0 0.125em rgba(50, 115, 220, 0.25)!important;
   }
   
   .hidethis{
   display:none;
   }
  .tablevisibility{
   border: 2px solid #BCBEC0; 
   border-collapse: collapse;  
   }
</style>
@endsection
@section('content')
<form class="m-form m-form--fit m-form--label-align-right m-form--group-seperator-dashed">
   <div class="m-content">
   <div class="row">
      <div class="col-lg-12">
         <div id="cardmesrausiaemas" class="m-portlet">
            <div class="m-portlet__head" >
               <div class="m-portlet__head-caption">
                  <div class="m-portlet__head-title">
                     <span class="m-portlet__head-icon m--hide">
                     <i class="la la-gear"></i>
                     </span>
                     <h3 id="mesrausiaemas" class="m-portlet__head-text"  >
                        MESRA USIA EMAS
                     </h3>
                  </div>
               </div>
            </div>
            <div class="m-portlet__body">
               <div class="m-form__section m-form__section--first maklumatpemohon">
                  <div class="m-form__heading">
                     <h3 id="maklumatpemohon" class="m-form__heading-title">
                        Maklumat Pemohon:
                     </h3>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>
                     Nama:
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" id="namapemohon" name="namapemohon" placeholder="Sila masukan nama">
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Tarikh Lahir:
                     </label>
                     <div class="col-lg-4">
                        <input type="date" data-date="" id="tarikhlahirpemohon" name="tarikhlahirpemohon" class="form-control m-input" data-date-format="MM DD YYYY">
                     </div>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Umur:
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" id="umurpemohon" name="umurpemohon" placeholder="Sila masukan umur">
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>No.Kad Pengenalan / No.Polis / No.Tentera:
                     </label>
                     <div class="input-group m-input-group col-lg-4">
                        <select class="m-input" id="ic_type" name="ic_type" style="font-size: 13px; color: #575962; border-color: #ebedf2; background-color: #f4f5f8" onchange="getIc($(this).val())">
                           <option value="1">No. K/P</option>
                           <option value="2">No. Tentera</option>
                           <option value="3">No. Polis</option>
                        </select>
                        <input type="text" class="form-control m-input" id="nokadpengenalanpemohon" name="nokadpengenalanpemohon" placeholder="Sila masukan no kad pengenalan" value="" onblur="checkDuplicate($(this).val(),'ic')" data-inputmask-regex="([a-zA-Z0-9 ])+/g" maxlength="12">
                     </div>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Jantina:
                     </label>
                     <div class="col-lg-4">
                        <div class="m-radio-list">
                           <label class="m-radio m-radio--solid m-radio--brand">
                           <input type="radio" name="inputlelakiperempuan" id="lelaki" value="lelaki">
                           Lelaki
                           <span></span>
                           </label>
                           <label class="m-radio m-radio--solid m-radio--brand">
                           <input type="radio" name="inputlelakiperempuan" id="perempuan" value="perempuan">
                           Perempuan
                           <span></span>
                           </label>
                        </div>
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Bangsa:
                     </label>
                     <div class="col-lg-4">
                        <select class="form-control m-input" id="bangsapemohon" name="bangsapemohon" onchange="getBangsaPemohon($(this).val())">
                           <option value="" hidden selected>Sila pilih bangsa</option>
                           <option value="Melayu">Melayu</option>
                           <option value="Cina">Cina</option>
                           <option value="India">India</option>
                        </select>
                     </div>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Agama:
                     </label>
                     <div class="col-lg-4">
                        <select id="agama" name="agama"  class="form-control m-input" onchange="getAgama($(this).val())" >
                           <option value="" hidden selected>Sila pilih agama</option>
                           <option value="Melayu">Melayu</option>
                           <option value="Cina">Cina</option>
                           <option value="India">India</option>
                           <option value="Lain-Lain">Lain-Lain</option>
                        </select>
                        <br/>
                        <input type="text" class="form-control m-input hidethis" id="agamalainlain" name="agamalainlain" placeholder="Sila masukan agama" >
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>No Telefon Bimbit:
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" id="notelefonbimbitpemohon" name="notelefonbimbitpemohon" placeholder="Sila masukan no telefon bimbit">
                     </div>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Pekerjaan:
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" id="pekerjaanpasangan" name="pekerjaanpasangan" placeholder="Sila masukan pekerjaan">
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Status Perkahwinan:
                     </label>
                     <div class="col-lg-4">
                        <select class="form-control m-input" id="statusperkahwinanpemohon" name="statusperkahwinanpemohon" onchange="getStatusPerkahwinan($(this).val())">
                           <option value="" hidden selected>Sila pilih status perkahwinan</option>
                           <option value="Bujang">Bujang</option>
                           <option value="Berkahwin">Berkahwin</option>
                           <option value="Duda/Janda">Duda/Janda</option>
                        </select>
                     </div>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Alamat:
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" name="alamat_1pemohon" placeholder="Sila masukan alamat">
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Poskod:
                     </label>
                     <div class="col-lg-4">
                        <input type="text" name="poskodpemohon" id="poskodpemohon" class="form-control m-input" placeholder="Sila masukan poskod">  
                     </div>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" id="alamat_2pemohon" name="alamat_2pemohon" placeholder="Sila masukan alamat">
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Bandar:
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" id="bandarpemohon" name="bandarpemohon" placeholder="Sila masukan bandar">
                     </div>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" name="alamat_3pemohon" id="alamat_3pemohon" placeholder="Sila masukan alamat">
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Negeri:
                     </label>
                     <div class="col-lg-4">
                        <select class="form-control m-input" id="negeripemohon" name="negeripemohon">
                           <option value="{{ old('') }}" hidden selected>Sila pilih negeri</option>
                           <option value="Johor">Johor</option>
                           <option value="Kedah">Kedah</option>
                           <option value="Kelantan">Kelantan</option>
                           <option value="Melaka">Melaka</option>
                           <option value="Negeri Sembilan">Negeri Sembilan</option>
                           <option value="Pahang">Pahang</option>
                           <option value="Penang">Penang</option>
                           <option value="Perak">Perak</option>
                           <option value="Perlis">Perlis</option>
                           <option value="Selangor">Selangor</option>
                           <option value="Terengganu">Terengganu</option>
                           <option value="Sabah">Sabah</option>
                           <option value="Sarawak">Sarawak</option>
                           <option value="W.P. Kuala Lumpur">W.P. Kuala Lumpur</option>
                           <option value="W.P. Labuan">W.P. Labuan</option>
                           <option value="W.P. Putrajaya">W.P. Putrajaya</option>
                        </select>
                     </div>
                  </div>
                  <div class="form-group m-form__group row">
                     <div class="col-lg-12">
                        <strong>Kesihatan - tandakan (/) pada yang berkenaan</strong>
                     </div>
                     <div class="col-lg-12">
                        <table id="pendapatanbulanantable" class="table order table-responsive tablevisibility">
                           <tbody>
                              <tr>
                                 <td class="col-lg-3 tablevisibility" id="kencingmanis"><strong>Kencing Manis</strong></td>
                                 <td id="rowtickkencingmanis" class="col-lg-1 tablevisibility"><input type="text" class="form-control m-input" id="tickkencingmanis" name="tickkencingmanis"></td>
                                 <td class="col-lg-3 tablevisibility" id="masalahjantung"><strong>Masalah Jantung</strong></td>
                                 <td id="rowtickmasalahjantung" class="col-lg-1 tablevisibility"><input type="text" class="form-control m-input" id="tickmasalahjantung" name="tickmasalahjantung"></td>
                                 <td class="col-lg-3 tablevisibility" id="kanser"><strong>Kanser</strong></td>
                                 <td id="rowtickkanser" class="col-lg-1 tablevisibility"><input type="text" class="form-control m-input" id="tickkanser" name="tickkanser"></td>
                              </tr>
                              <tr>
                                 <td class="col-lg-3 tablevisibility" id="kencingmanis"><strong>Darah Tinggi</strong></td>
                                 <td id="rowtickdarahtinggi" class="col-lg-=1 tablevisibility"><input type="text" class="form-control m-input" id="tickdarahtinggi" name="tickdarahtinggi"></td>
                                 <td class="col-lg-3 tablevisibility" id="masalahjantung"><strong>Masalah Kencing</strong></td>
                                 <td id="rowtickmasalahkencing" class="col-lg-1 tablevisibility"><input type="text" class="form-control m-input" id="tickmasalahkencing" name="tickmasalahkencing"></td>
                                 <td class="col-lg-3 tablevisibility" id="kanser"><strong>Nyanyuk</strong></td>
                                 <td id="rowticknyanyuk" class="col-lg-1 tablevisibility"><input type="text" class="form-control m-input" id="ticknyanyuk" name="ticknyanyuk"></td>
                              </tr>
                              <tr>
                                 <td class="col-lg-3 tablevisibility" id="kencingmanis"><strong>Angin Ahamr</strong></td>
                                 <td id="rowtickanginahmar" class="col-lg-1 tablevisibility"><input type="text" class="form-control m-input" id="tickanginahmar" name="tickanginahmar"></td>
                                 <td class="col-lg-3 tablevisibility" id="masalahjantung"><strong>Masalah Mata</strong></td>
                                 <td id="rowtickmasalahmata" class="col-lg-1 tablevisibility"><input type="text" class="form-control m-input" id="tickmasalahmata" name="tickmasalahmata"></td>
                                 <td class="col-lg-3 tablevisibility" id="kanser"><strong>OKU</strong></td>
                                 <td id="rowtickOKU" class="col-lg-1 tablevisibility"><input type="text" class="form-control m-input" id="tickOKU" name="tickOKU"></td>
                              </tr>
                              <tr>
                                 <td class="col-lg-3 tablevisibility" id="kencingmanis"><strong>Sakit Sendi</strong></td>
                                 <td id="rowticksakitsendi" class="col-lg-1 tablevisibility"><input type="text" class="form-control m-input" id="ticksakitsendi" name="ticksakitsendi"></td>
                                 <td class="col-lg-3 tablevisibility" id="masalahjantung"><strong>Buah Pinggang</strong></td>
                                 <td id="rowtickbuahpinggang" class="col-lg-1 tablevisibility"><input type="text" class="form-control m-input" id="tickbuahpinggang" name="tickbuahpinggang"></td>
                                 <td class="col-lg-3 tablevisibility" id="kanser"><strong>Epilepsi</strong></td>
                                 <td id="rowtickepilepsi" class="col-lg-1 tablevisibility"><input type="text" class="form-control m-input" id="tickepilepsi" name="tickepilepsi"></td>
                              </tr>
                           </tbody>
                        </table>
                     </div>
                  </div>
               </div>
               <div class="m-form__seperator m-form__seperator--dashed maklumatpenjagapemohon"></div>
               <div class="m-form__section m-form__section--middle maklumatpenjagapemohon">
                  <div class="m-form__heading">
                     <h3 class="m-form__heading-title">
                        Maklumat Penjaga Pemohon:
                     </h3>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>
                     Nama:
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" id="namapenjaga" name="namapenjaga" placeholder="Sila masukan nama">
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Jantina:
                     </label>
                     <div class="col-lg-4">
                        <div class="m-radio-list">
                           <label class="m-radio m-radio--solid m-radio--brand">
                           <input type="radio" name="inputlelakiperempuan" id="lelaki" value="lelaki">
                           Lelaki
                           <span></span>
                           </label>
                           <label class="m-radio m-radio--solid m-radio--brand">
                           <input type="radio" name="inputlelakiperempuan" id="perempuan" value="perempuan">
                           Perempuan
                           <span></span>
                           </label>
                        </div>
                     </div>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Bangsa:
                     </label>
                     <div class="col-lg-4">
                        <select class="form-control m-input" id="bangsapenjaga" name="bangsapenjaga" onchange="getBangsaPemohon($(this).val())">
                           <option value="" hidden selected>Sila pilih bangsa</option>
                           <option value="Melayu">Melayu</option>
                           <option value="Cina">Cina</option>
                           <option value="India">India</option>
                        </select>
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Hubungan dengan pemohon:
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" id="hubunganpenjagadenganpemohon" name="hubunganpenjagadenganpemohon" placeholder="Sila masukan hubungan dengan pemohon">
                     </div>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Emel:
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" id="emelpenjaga" name="emelpenjaga" placeholder="Sila masukkan emel" onblur="checkEmail($(this))" >
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>No.Kad Pengenalan / No.Polis / No.Tentera:
                     </label>
                     <div class="input-group m-input-group col-lg-4">
                        <select class="m-input" id="ic_type" name="ic_type" style="font-size: 13px; color: #575962; border-color: #ebedf2; background-color: #f4f5f8" onchange="getIc($(this).val())">
                           <option value="1">No. K/P</option>
                           <option value="2">No. Tentera</option>
                           <option value="3">No. Polis</option>
                        </select>
                        <input type="text" class="form-control m-input" id="nokadpengenalanpenjaga" name="nokadpengenalanpenjaga" placeholder="Sila masukan no kad pengenalan" value="" onblur="checkDuplicate($(this).val(),'ic')" data-inputmask-regex="([a-zA-Z0-9 ])+/g" maxlength="12">
                     </div>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Alamat:
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" name="alamat_1pemohon" placeholder="Sila masukan alamat">
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Poskod:
                     </label>
                     <div class="col-lg-4">
                        <input type="text" name="poskodpenjaga" id="poskodpenjaga" class="form-control m-input" placeholder="Sila masukan alamat">  
                     </div>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" id="alamat_2majikanpenjaga" name="alamat_2majikanpenjaga" placeholder="Sila masukan alamat">
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Bandar:
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" id="bandarmajikanpenjaga" name="bandarmajikanpenjaga" placeholder="Sila masukan bandar">
                     </div>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" id="alamat_3majikanpenjaga" name="alamat_3majikanpenjaga" placeholder="Sila masukan alamat">
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Negeri:
                     </label>
                     <div class="col-lg-4">
                        <select class="form-control m-input" id="negerimajikanpenjaga" name="negerimajikanpenjaga">
                           <option value="{{ old('') }}" hidden selected>Sila pilih negeri</option>
                           <option value="Johor">Johor</option>
                           <option value="Kedah">Kedah</option>
                           <option value="Kelantan">Kelantan</option>
                           <option value="Melaka">Melaka</option>
                           <option value="Negeri Sembilan">Negeri Sembilan</option>
                           <option value="Pahang">Pahang</option>
                           <option value="Penang">Penang</option>
                           <option value="Perak">Perak</option>
                           <option value="Perlis">Perlis</option>
                           <option value="Selangor">Selangor</option>
                           <option value="Terengganu">Terengganu</option>
                           <option value="Sabah">Sabah</option>
                           <option value="Sarawak">Sarawak</option>
                           <option value="W.P. Kuala Lumpur">W.P. Kuala Lumpur</option>
                           <option value="W.P. Labuan">W.P. Labuan</option>
                           <option value="W.P. Putrajaya">W.P. Putrajaya</option>
                        </select>
                     </div>
                  </div>
               </div>
               <div class="m-form__seperator m-form__seperator--dashed maklumatpenjagakeduapemohon"></div>
               <div class="m-form__section m-form__section--middle maklumatpenjagakeduapemohon">
                  <div class="m-form__heading">
                     <h3 class="m-form__heading-title">
                        Maklumat Penjaga 2 Pemohon:
                     </h3>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>
                     Nama:
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" id="namapenjagakedua" name="namapenjagakedua" placeholder="Sila masukan nama">
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Jantina:
                     </label>
                     <div class="col-lg-4">
                        <div class="m-radio-list">
                           <label class="m-radio m-radio--solid m-radio--brand">
                           <input type="radio" name="inputlelakiperempuan" id="lelaki" value="lelaki">
                           Lelaki
                           <span></span>
                           </label>
                           <label class="m-radio m-radio--solid m-radio--brand">
                           <input type="radio" name="inputlelakiperempuan" id="perempuan" value="perempuan">
                           Perempuan
                           <span></span>
                           </label>
                        </div>
                     </div>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Bangsa:
                     </label>
                     <div class="col-lg-4">
                        <select class="form-control m-input" id="bangsapenjagakedua" name="bangsapenjagakedua" onchange="getBangsaPemohon($(this).val())">
                           <option value="" hidden selected>Sila pilih bangsa</option>
                           <option value="Melayu">Melayu</option>
                           <option value="Cina">Cina</option>
                           <option value="India">India</option>
                        </select>
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Hubungan dengan pemohon:
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" id="hubunganpenjagakeduadenganpemohon" name="hubungandenganpemohon" placeholder="Sila masukan hubungan dengan pemohon">
                     </div>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Emel:
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" id="emelpenjagakedua" name="emelpenjagakedua" placeholder="Sila masukkan emel" onblur="checkEmail($(this))" >
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>No.Kad Pengenalan / No.Polis / No.Tentera:
                     </label>
                     <div class="input-group m-input-group col-lg-4">
                        <select class="m-input" id="ic_type" name="ic_type" style="font-size: 13px; color: #575962; border-color: #ebedf2; background-color: #f4f5f8" onchange="getIc($(this).val())">
                           <option value="1">No. K/P</option>
                           <option value="2">No. Tentera</option>
                           <option value="3">No. Polis</option>
                        </select>
                        <input type="text" class="form-control m-input" id="nokadpengenalanpenjagakedua" name="nokadpengenalanpenjagakeduapemohon" placeholder="Sila masukan no kad pengenalan" value="" onblur="checkDuplicate($(this).val(),'ic')" data-inputmask-regex="([a-zA-Z0-9 ])+/g" maxlength="12">
                     </div>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Alamat:
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" name="alamat_1penjagakedua" placeholder="Sila masukan alamat">
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Poskod:
                     </label>
                     <div class="col-lg-4">
                        <input type="text" name="poskodpenjagakedua" id="poskodpenjagakedua" class="form-control m-input" placeholder="Sila masukan poskod">  
                     </div>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" id="alamat_2majikanpenjagakedua" name="alamat_2majikanpenjagakedua" placeholder="Sila masukan alamat">
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Bandar:
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" id="bandarmajikanpenjagakedua" name="bandarmajikanpenjagakedua" placeholder="Sila masukan bandar">
                     </div>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" id="alamat_3majikanpenjagakedua" name="alamat_3majikanpenjagakedua" placeholder="Sila masukan alamat">
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Negeri:
                     </label>
                     <div class="col-lg-4">
                        <select class="form-control m-input" id="negerimajikanpenjagakedua" name="negerimajikanpenjagakedua">
                           <option value="{{ old('') }}" hidden selected>Sila pilih negeri</option>
                           <option value="Johor">Johor</option>
                           <option value="Kedah">Kedah</option>
                           <option value="Kelantan">Kelantan</option>
                           <option value="Melaka">Melaka</option>
                           <option value="Negeri Sembilan">Negeri Sembilan</option>
                           <option value="Pahang">Pahang</option>
                           <option value="Penang">Penang</option>
                           <option value="Perak">Perak</option>
                           <option value="Perlis">Perlis</option>
                           <option value="Selangor">Selangor</option>
                           <option value="Terengganu">Terengganu</option>
                           <option value="Sabah">Sabah</option>
                           <option value="Sarawak">Sarawak</option>
                           <option value="W.P. Kuala Lumpur">W.P. Kuala Lumpur</option>
                           <option value="W.P. Labuan">W.P. Labuan</option>
                           <option value="W.P. Putrajaya">W.P. Putrajaya</option>
                        </select>
                     </div>
                  </div>
               </div>
               <div class="m-form__seperator m-form__seperator--dashed pengesahantarafmastautinpemohon"></div>
               <div class="m-form__section m-form__section--middle pengesahantarafmastautinpemohon">
                  <div class="m-form__heading">
                     <h3 class="m-form__heading-title">
                        Pengesahan Taraf Mastautin Pemohon:
                     </h3>
                  </div>
                  <div class="form-group m-form__group row">
                     <div class="col-lg-12">
                        Saya mengaku bahawa warga emas ini telah bermastautin secara sah sekurang -kurangnya 15 tahun di Negeri Selangor. 
                        (Bahagian ini perlu diisi sekiranya watga emas yang memohon bukan kelahiran Selangor - MyKad tidak berkod 10)
                     </div>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>
                     Nama:
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" id="namapenjagakedua" name="namapenjagakedua" placeholder="Sila masukan nama">
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>No.Kad Pengenalan / No.Polis / No.Tentera:
                     </label>
                     <div class="input-group m-input-group col-lg-4">
                        <select class="m-input" id="ic_type" name="ic_type" style="font-size: 13px; color: #575962; border-color: #ebedf2; background-color: #f4f5f8" onchange="getIc($(this).val())">
                           <option value="1">No. K/P</option>
                           <option value="2">No. Tentera</option>
                           <option value="3">No. Polis</option>
                        </select>
                        <input type="text" class="form-control m-input" id="nokadpengenalanpenjagakedua" name="nokadpengenalanpenjagakeduapemohon" placeholder="Sila masukan no kad pengenalan" value="" onblur="checkDuplicate($(this).val(),'ic')" data-inputmask-regex="([a-zA-Z0-9 ])+/g" maxlength="12">
                     </div>
                  </div>
                  <div class="form-group m-form__group row">
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>No Telefon Bimbit:
                     </label>
                     <div class="col-lg-4">
                        <input type="text" class="form-control m-input" id="notelefonbimbitpemohon" name="notelefonbimbitpemohon" placeholder="Sila masukan no telefon bimbit">
                     </div>
                     <label class="col-lg-2 col-form-label">
                     <span style="color: red">* </span>Jawatan - tandakan (/) pada yang berkenaan
                     </label>
                     <div class="col-lg-4">
                        <table id="pengesahantarafmastautintable" class="table order table-responsive tablevisibility">
                           <tbody>
                              <tr>
                                 <td id="rowtickahliparlimensenator" class="col-lg-1 tablevisibility"><input type="text" class="form-control m-input" id="tickahliparlimensenator" name="tickahliparlimensenator"></td>
                                 <td class="col-lg-3 tablevisibility" id="ahliparlimensenator"><strong>Ahli Parlimen Senator</strong></td>
                              </tr>
                              <tr>
                                 <td id="rowtickadunpengerusijkpenyelarasdun" class="col-lg-1 tablevisibility"><input type="text" class="form-control m-input" id="tickadunpengerusijkpenyelarasdun" name="tickadunpengerusijkpenyelarasdun"></td>
                                 <td class="col-lg-3 tablevisibility" id="adunpengerusijkpenyelarasdun"><strong>ADUN / Pengerusi JK Penyelaras DUN</strong></td>
                              </tr>
                              <tr>
                                 <td id="rowtickpenghuluketuakampung" class="col-lg-1 tablevisibility"><input type="text" class="form-control m-input" id="tickpenghuluketuakampung" name="tickpenghuluketuakampung"></td>
                                 <td class="col-lg-3 tablevisibility" id="penghuluketuakampung"><strong>Penghulu /Ketua Kampung</strong></td>
                              </tr>
                              <tr>
                                 <td id="rowtickahlimajlispihakberkuasatempatan" class="col-lg-1 tablevisibility"><input type="text" class="form-control m-input" id="tickahlimajlispihakberkuasatempatan" name="tickahlimajlispihakberkuasatempatan"></td>
                                 <td class="col-lg-3 tablevisibility" id="ahlimajlispihakberkuasatempatan"><strong>Ahli Majlis Pihak Berkuasa Tempatan</strong></td>
                              </tr>
                              <tr>
                                 <td id="rowtickpengerusitamanperumahan" class="col-lg-1 tablevisibility"><input type="text" class="form-control m-input" id="tickpengerusitamanperumahan" name="tickpengerusitamanperumahan"></td>
                                 <td class="col-lg-3 tablevisibility" id="pengerusitamanperumahan"><strong>Pengerusi Taman Perumahan</strong></td>
                              <tr>
                                 <td id="rowticknazirketuatokongkuilgereja" class="col-lg-1 tablevisibility"><input type="text" class="form-control m-input" id="ticknazirketuatokongkuilgereja" name="ticknazirketuatokongkuilgereja"></td>
                                 <td class="col-lg-3 tablevisibility" id="nazirketuatokongkuilgereja"><strong>Nazir / Ketua Tokong / kuil / Gereja</strong></td>
                              </tr>
                           </tbody>
                        </table>
                     </div>
                  </div>
                  <div class="m-form__seperator m-form__seperator--dashed pengesahanpusarpendaftaran"></div>
                  <div class="m-form__section m-form__section--middle pengesahanpusatpendaftaran">
                     <div class="m-form__heading">
                        <h3 class="m-form__heading-title">
                           Pengesahan Pusat Pendaftaran:
                        </h3>
                     </div>
                     <div class="form-group m-form__group row">
                        <div class="col-lg-12">
                           Saya mengaku bahawa satu salinan telah diserahkan kepada warga emas,satu salinan disimpan 
                           Pusat Pendaftaran dari salinan asal serta salinan MyKad Pemnohon, Penjaga, Penama tlah dihantar kepada YAWAS
                        </div>
                     </div>
                     <div class="form-group m-form__group row">
                        <label class="col-lg-2 col-form-label">
                        <span style="color: red">* </span>
                        Nama:
                        </label>
                        <div class="col-lg-4">
                           <input type="text" class="form-control m-input" id="namapenjagakedua" name="namapenjagakedua" placeholder="Sila masukan nama">
                        </div>
                        <label class="col-lg-2 col-form-label">
                        <span style="color: red">* </span>
                        Nama DUN:
                        </label>
                        <div class="col-lg-4">
                           <input type="text" class="form-control m-input" id="namadunpenjagakedua" name="namadunpenjagakedua" placeholder="Sila masukan nama DUN">
                        </div>
                     </div>
                     <div class="form-group m-form__group row">
                        <label class="col-lg-2 col-form-label">
                        <span style="color: red">* </span>
                        Nama Petugas:
                        </label>
                        <div class="col-lg-4">
                           <input type="text" class="form-control m-input" id="namapetugaspenjagakedua" name="namapetugaspenjagakedua" placeholder="Sila masukan nama petugas">
                        </div>
                        <label class="col-lg-2 col-form-label">
                        <span style="color: red">* </span>
                        No.Kad Pengenalan Bertugas:
                        </label>
                        <div class="col-lg-4">
                           <input type="text" class="form-control m-input" id="nokadpengenalanbertugas" name="nokadpengenalanbertugas" placeholder="Sila masukan no kad pengenalan" value="" onblur="checkDuplicate($(this).val(),'ic')" data-inputmask-regex="([a-zA-Z0-9 ])+/g" maxlength="12">
                        </div>
                     </div>
                     <div class="form-group m-form__group row">
                        <label class="col-lg-2 col-form-label">
                        <span style="color: red">* </span>
                        Tarikh Borang Diterima:
                        </label>
                        <div class="col-lg-4">
                           <input type="text" class="form-control m-input" id="tarikhborangditerima" name="tarikhborangditerima" placeholder="Sila masukan tarikh borang diterima">
                        </div>
                     </div>
                  </div>
                  <div class="m-form__seperator m-form__seperator--dashed dokumentasiyawas"></div>
                  <div class="m-form__section m-form__section--middle dokumentasiyawas">
                     <div class="m-form__heading">
                        <h3 class="m-form__heading-title">
                           Dokumentasi YAWAS:
                        </h3>
                     </div>
                     <div class="form-group m-form__group row">
                        <label class="col-lg-2 col-form-label">
                        <span style="color: red">* </span>
                        Tarikh Borang Diterima:
                        </label>
                        <div class="col-lg-4">
                           <input type="text" class="form-control m-input" id="tarikhborangditerima" name="tarikhborangditerima" placeholder="Sila masukan tarikh borang diterima">
                        </div>
                        <label class="col-lg-2 col-form-label">
                        <span style="color: red">* </span>
                        Semakan Ahli:
                        </label>
                        <div class="col-lg-4">
                           <input type="text" class="form-control m-input" id="semakanahli" name="semakanahli" placeholder="Sila masukan semakan ahli">
                        </div>
                     </div>
                     <div class="form-group m-form__group row">
                        <label class="col-lg-2 col-form-label">
                        <span style="color: red">* </span>
                        Semakan Penjaga Ahli:
                        </label>
                        <div class="col-lg-4">
                           <input type="text" class="form-control m-input" id="semakanpenjagaahli" name="semakanpoenjagaahli" placeholder="Sila masukan semakan penjaga ahli">
                        </div>
                        <label class="col-lg-2 col-form-label">
                        <span style="color: red">* </span>
                        Semakan Penama Ahli:
                        </label>
                        <div class="col-lg-4">
                           <input type="text" class="form-control m-input" id="semakanpenamaahli" name="semakanpenamaahli" placeholder="Sila masukan semakan penama ahli">
                        </div>
                     </div>
                  </div>
               </div>
            </div>
         </div>
      </div>
   </div>
</form>
@endsection
@section('js')
<script src="../../../assets/vendors/base/vendors.bundle.js" type="text/javascript"></script>
<script src="../../../assets/demo/default/base/scripts.bundle.js" type="text/javascript"></script>
<script>
   $("#nokadpengenalanpemohon,#nokadpengenalansuamiisteri").inputmask({mask: "999999999999", placeholder: ""});
   
   $("#poskodpemohon,#poskodpenjaga,#poskodpenjagakedua").inputmask({mask: "99999", placeholder: ""});
   
   $('#notelefonbimbitpemohon,#notelefonbimbitsuamiisteri,#notelefonmajikansuamiisteri,#notelefonmajikanpemohon').inputmask('Regex', { regex: "^(01)[0-9]{8,9}$"}); 
   
   $("#pendapatanbulananpemohon,#pendapatanbulananpasangan").inputmask({mask: "9999999",placeholder: ""});
   
   $('#notelefonrumahpemohon,#notelefonrumahsuamiisteri').inputmask('Regex', { regex: "^(03)[0-9]{8}$"});
   
   $("#tempohtinggaldiselangorpasangan,#tempohtinggaldiselangorpemohon").inputmask({mask: "99",placeholder: ""});
   
   $("#pendapatansendiri, #pendapatananakanak, #pendapatanlainlain,#pendapatanpasangan, #jumlahpendapatan").inputmask({mask: "9999999",placeholder: ""});
   

   function checkEmail(x) {
       var email_format = /^(([^<>()\[\]\\.,;:\s@"]+(\.[^<>()\[\]\\.,;:\s@"]+)*)|(".+"))@((\[[0-9]{1,3}\.[0-9]{1,3}\.[0-9]{1,3}\.[0-9]{1,3}\])|(([a-zA-Z\-0-9]+\.)+[a-zA-Z]{2,}))$/;
   
           x.next().remove();
               
           if(x.val().match(email_format)) {
                   x.next().remove();
               } else if(x.val() == '') {
                   x.next().remove();
               } else {
                   x.after("<small style='color: #f4516c'>Sila masukkan format emel yang betul.</small>");
                   x.focus();
               }
           }
</script>
@endsection