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mypage.php
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mypage.php
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<!DOCTYPE html>
<html lang="en">
<head>
<title>Bootstrap Example</title>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1">
<link rel="stylesheet" href="https://maxcdn.bootstrapcdn.com/bootstrap/3.3.7/css/bootstrap.min.css">
<script src="https://ajax.googleapis.com/ajax/libs/jquery/3.3.1/jquery.min.js"></script>
<script src="https://maxcdn.bootstrapcdn.com/bootstrap/3.3.7/js/bootstrap.min.js"></script>
<script type="text/javascript"></script></head>
<body>
<div class="container">
<div class="row">
<div class="col-xs-5" style="border-top:4px solid black">
<h2>Global Home Health Care
Application For Employment</h2>
</div>
<div class="col-xs-2" style="border-top:4px solid black;background-color:#E7E6E6">
<p>We are an Equal
Opportunity Employer and
committed to excellence
through diversity</p>
</div>
<div class="col-xs-3" style="border-top:4px solid black;background-color:#E7E6E6">
<p>Please print or type. The
application must be fully
completed to be
considered. Please
complete each section,
even if you attach a
resume.</p>
</div>
</div>
</div><br><br><br><br>
<div class="container">
<div class="row">
<div class="col-xs-12" style="width: 936px;">
<h3 style="color:white;background-color:#2F5496;padding:20px">Personal Information</h3>
</div>
</div>
</div><br><br><br><br>
<form action="/action_page.php">
<div class="container">
<div class="row"><br>
<div class="col-xs-5" style="width: 438px;">
<div class="form-group">
<label for="name">First name *</label>
<input type="text" class="form-control" id="email" value="<?=$f_name?>" name="email">
</div>
</div>
<div class="col-xs-5" style="width: 468px;">
<div class="form-group">
<label for="name">Last name *</label>
<input type="text" class="form-control" id="email" value="<?=$l_name?>" name="email">
</div>
</div>
</div>
</div><br><br><br>
<div class="container">
<div class="row"><br><br>
<div class="col-xs-3" style="width: 329px;">
<div class="form-group">
<label for="email">Address</label>
<input type="text" class="form-control" id="email" value="<?=$address?>" name="email">
</div>
</div>
<div class="col-xs-2">
<div class="form-group">
<label for="email">City</label>
<input type="text" class="form-control" id="email" value="<?=$city?>" name="email">
</div>
</div>
<div class="col-xs-2">
<div class="form-group">
<label for="email">State</label>
<input type="text" class="form-control" id="email" value="<?=$state?>" name="email">
</div>
</div>
<div class="col-xs-2">
<div class="form-group">
<label for="email">Zip</label>
<input type="text" class="form-control" id="email" value="<?=$zip?>" name="email">
</div>
</div>
</div>
</div><br><br><br><br>
<div class="container">
<div class="row"><br><br>
<div class="col-xs-3" style="width: 220px;">
<div class="form-group">
<label for="email">Home Phone *</label>
<input type="text" class="form-control" id="email" value="<?=$home_phone?>" name="email">
</div>
</div>
<div class="col-xs-2" style="width: 220px;">
<div class="form-group">
<label for="email">Cell Phone </label>
<input type="text" class="form-control" id="email" value="<?=$cell_phone?>" name="email">
</div>
</div>
<div class="col-xs-2" style="width: 220px;">
<div class="form-group">
<label for="email">Alternative Number</label>
<input type="text" class="form-control" id="email" value="<?=$alternative_number?>" name="email">
</div>
</div>
<div class="col-xs-2" style="width: 185px;">
<div class="form-group">
<label for="email">Gender *</label>
<input type="text" class="form-control" id="email" value="<?=$gender?>" name="email">
</div>
</div>
</div>
</div><br><br><br>
<div class="container">
<div class="row"><br><br><br>
<div class="col-xs-5" style="width: 438px;">
<div class="form-group">
<label for="email">Date OF Birth *</label>
<input type="text" class="form-control" id="email" value="<?=$dob?>" name="email">
</div>
</div>
<div class="col-xs-5" style="width: 468px;">
<div class="form-group">
<label for="email">Email address</label>
<input type="text" class="form-control" id="email" value="<?=$email?>" name="email">
</div>
</div>
</div>
</div><br><br><br>
<div class="container">
<div class="row"><br><br><br><br><br>
<div class="col-xs-5" style="width: 438px;">
<div class="form-group">
<label for="email">Are you legally eligible to work in the US?</label><br>
<label class="checkbox-inline">
<input type="checkbox" value="" <?php if($are_you_legally_yes==1){echo"checked";} ?>>Yes
</label>
<label class="checkbox-inline" style=" margin-left: 125px;">
<input type="checkbox" value="" <?php if($are_you_legally_no==1){echo"checked";} ?> >No
</label>
</div>
</div>
<div class="col-xs-5" style="width: 438px;">
<div class="form-group">
<label for="email">Are you a veteran?</label><br>
<label class="checkbox-inline" >
<input type="checkbox" value="" <?php if($are_u_veteran_yes==1){echo"checked";} ?> >Yes
</label>
<label class="checkbox-inline" style=" margin-left: 125px;">
<input type="checkbox" value="" <?php if($are_u_veteran_no==1){echo"checked";} ?>>No
</label>
</div>
</div>
</div>
</div>
</div><br><br><br>
<div class="container">
<div class="row"><br><br><br><br><br>
<div class="col-xs-10" style="width: 838px;">
<div class="form-group">
<label for="email">If selected for employment are you willing to submit to a background check?</label><br>
<label class="checkbox-inline">
<input type="checkbox" value="" <?php if($if_seleted_for_yes==1){echo"checked";} ?>>Yes
</label>
<label class="checkbox-inline" style=" margin-left: 125px;">
<input type="checkbox" value="" <?php if($if_seleted_for_no==1){echo"checked";} ?> >No
</label>
</div>
</div>
</div>
</div><br><br><br><br><br><br><br><br><br><br>
<div class="container">
<div class="row"><br><br><br><br><br>
<div class="col-xs-10" style="width: 838px;">
<div class="form-group">
<label for="email">Are you willing to work within a 25-50 mile radius? *</label><br>
<label class="checkbox-inline">
<input type="checkbox" value="" <?php if($are_u_willing_yes==1){echo"checked";} ?>>Yes
</label>
<label class="checkbox-inline" style=" margin-left: 125px;">
<input type="checkbox" value="" <?php if($are_u_willing_no==1){echo"checked";} ?> >No
</label>
</div>
</div>
</div>
</div><br><br><br><br><br><br>
<div class="container">
<div class="row"><br><br>
<div class="col-xs-11" style="width: 906px;">
<div class="form-group">
<label for="email">What experiences do you have working with the elderly, handicapped children, and behavior problems?</label><br><br>
<div class="col-xs-12" style="width: 900px;border:1px solid #E7E6E6;">
<h3 style="color:black;padding:10px;font-size: 14px;"><?=$what_experience?></h3>
</div>
</div>
</div>
</div>
</div><br><br><br><br><br><br><br><br><br><br><br>
<div class="container">
<div class="row">
<div class="col-xs-12" style="width: 936px;">
<h3 style="color:white;background-color:#2F5496;padding:20px">Position</h3>
</div>
</div>
</div><br><br><br>
<div class="container">
<div class="row"><br><br>
<div class="col-xs-3" style="width: 329px;">
<div class="form-group">
<label for="email">Position you are applying for</label>
<input type="text" class="form-control" id="email" value="<?=$position?>" name="email">
</div>
</div>
<div class="col-xs-3" style="width: 291px;">
<div class="form-group">
<label for="email">Desired Locations</label>
<input type="text" class="form-control" id="email" value="<?=$desired_location?>" name="email">
</div>
</div>
<div class="col-xs-3">
<div class="form-group">
<label for="email">Available start date</label>
<input type="text" class="form-control" id="email" value="<?=$available_start_date?>" name="email">
</div>
</div>
</div>
</div><br><br><br>
<div class="container">
<div class="row"><br><br><br><br>
<div class="col-xs-10" style="width: 838px;">
<div class="form-group">
<label for="email">Employment desired</label><br>
<label class="checkbox-inline">
<input type="checkbox" value="" <?php if($full_time==1){echo"checked";} ?>>Full time
</label>
<label class="checkbox-inline" style=" margin-left: 125px;">
<input type="checkbox" value="" <?php if($part_time==1){echo"checked";} ?> >Part time
</label>
<label class="checkbox-inline" style=" margin-left: 125px;">
<input type="checkbox" value="" <?php if($seasonal==1){echo"checked";} ?> >Seasonal/Temporary
</label>
</div>
</div>
</div>
</div>
<br><br><br><br><br><br><br><br><br>
<div class="container">
<div class="row">
<div class="col-xs-12" style="width: 936px;">
<h3 style="color:white;background-color:#2F5496;padding:20px">Education</h3>
</div>
</div>
</div><br><br><br><br><br>
<div class="container">
<div class="row">
<div class="col-xs-12" style="width: 936px;">
<table class="table table-bordered">
<thead>
<tr>
<th>School name</th>
<th>Location</th>
<th>Years attended</th>
<th>Degree received</th>
<th>Major</th>
</tr>
</thead>
<tbody>
<tr>
<td><?=$school_name1?></td>
<td><?=$school_name2?></td>
<td><?=$school_name3?></td>
<td><?=$school_name4?></td>
<td><?=$school_name5?></td>
</tr>
<tr>
<td><?=$location1?></td>
<td><?=$location2?></td>
<td><?=$location3?></td>
<td><?=$location4?></td>
<td><?=$location5?></td>
</tr>
<tr>
<td><?=$years_attended1?></td>
<td><?=$years_attended2?></td>
<td><?=$years_attended3?></td>
<td><?=$years_attended4?></td>
<td><?=$years_attended5?></td>
</tr>
</tbody>
</table>
</div>
</div>
</div><br><br><br><br><br><br><br><br>
<div class="container">
<div class="row">
<div class="col-xs-12" style="width: 936px;">
<h3 style="color:white;background-color:#2F5496;padding:20px">References <span style="font-size:16px">(business and professional only)</span></h3>
</div>
</div>
</div><br><br><br><br><br>
<div class="container">
<div class="row">
<div class="col-xs-12" style="width: 936px;">
<table class="table table-bordered">
<thead>
<tr>
<th>Name</th>
<th>Title</th>
<th>Company</th>
<th>Phone</th>
</tr>
</thead>
<tbody>
<tr>
<td><?=$reference_name1?></td>
<td><?=$reference_name2?></td>
<td><?=$reference_name3?></td>
<td><?=$reference_name4?></td>
</tr>
<tr>
<td><?=$reference_title1?></td>
<td><?=$reference_title2?></td>
<td><?=$reference_title3?></td>
<td><?=$reference_title4?></td>
</tr>
<tr>
<td><?=$reference_company1?></td>
<td><?=$reference_company2?></td>
<td><?=$reference_company3?></td>
<td><?=$reference_company4?></td>
</tr>
</tbody>
</table>
</div>
</div>
</div><br><br><br>
<br><br><br>
<div class="container">
<div class="row"><br><br><br><br><br>
<div class="col-xs-10" style="width: 838px;">
<div class="form-group">
<label for="email">Check Days You Can Work: *</label><br>
<label class="checkbox-inline">
<input type="checkbox" value="" <?php if($m==1){echo"checked";} ?> >M
</label>
<label class="checkbox-inline" style=" margin-left: 80px;">
<input type="checkbox" value="" <?php if($tu==1){echo"checked";} ?> >TU
</label>
<label class="checkbox-inline" style=" margin-left: 80px;">
<input type="checkbox" value="" <?php if($w==1){echo"checked";} ?> >W
</label>
<label class="checkbox-inline" style=" margin-left: 80px;">
<input type="checkbox" value="" <?php if($th==1){echo"checked";} ?> >TH
</label>
<label class="checkbox-inline" style=" margin-left: 80px;">
<input type="checkbox" value="" <?php if($f==1){echo"checked";} ?> >F
</label>
<label class="checkbox-inline" style=" margin-left: 80px;">
<input type="checkbox" value="" <?php if($sa==1){echo"checked";} ?> >SA
</label>
<label class="checkbox-inline" style=" margin-left: 80px;">
<input type="checkbox" value="" <?php if($su==1){echo"checked";} ?> >SU
</label>
</div>
</div>
</div>
</div><br><br><br><br><br><br><br><br><br><br>
<div class="container">
<div class="row">
<div class="col-xs-12" style="width: 936px;">
<h3 style="color:white;background-color:#2F5496;padding:20px">Employment History</h3>
</div>
</div>
</div><br><br><br>
<div class="container">
<div class="row"><br><br>
<div class="col-xs-3" style="width: 329px;">
<div class="form-group">
<label for="email"><b>Employer (1)</b></label>
<input type="text" class="form-control" id="email" value="<?=$employer1_name?>" name="email">
</div>
</div>
<div class="col-xs-3" style="width: 291px;">
<div class="form-group">
<label for="email">Job title</label>
<input type="text" class="form-control" id="email" value="<?=$employer1_title?>" name="email">
</div>
</div>
<div class="col-xs-3">
<div class="form-group">
<label for="email">Dates employed</label>
<input type="text" class="form-control" id="email" value="<?=$employer1_date?>" name="email">
</div>
</div>
</div>
</div><br><br><br>
<div class="container">
<div class="row"><br><br><br>
<div class="col-xs-3" style="width: 329px;">
<div class="form-group">
<label for="email">Work phone</label>
<input type="text" class="form-control" id="email" value="<?=$employer1_workphone?>" name="email">
</div>
</div>
<div class="col-xs-3" style="width: 291px;">
<div class="form-group">
<label for="email">Starting pay rate</label>
<input type="text" class="form-control" id="email" value="<?=$employer1_starting_payrate?>" name="email">
</div>
</div>
<div class="col-xs-3">
<div class="form-group">
<label for="email">Ending pay rate</label>
<input type="text" class="form-control" id="email" value="<?=$employer1_ending_payrate?>" name="email">
</div>
</div>
</div>
</div><br><br><br>
<div class="container">
<div class="row"><br><br><br><br>
<div class="col-xs-3" style="width: 329px;">
<div class="form-group">
<label for="email">Address</label>
<input type="text" class="form-control" id="email" value="<?=$employer1_address?>" name="email">
</div>
</div>
<div class="col-xs-3" style="width: 125px;">
<div class="form-group">
<label for="email">City</label>
<input type="text" class="form-control" id="email" value="<?=$employer1_city?>" name="email">
</div>
</div>
<div class="col-xs-3" style="width: 136px;">
<div class="form-group">
<label for="email">State</label>
<input type="text" class="form-control" id="email" value="<?=$employer1_state?>" name="email">
</div>
</div>
<div class="col-xs-3">
<div class="form-group">
<label for="email">Zip</label>
<input type="text" class="form-control" id="email" value="<?=$employer1_zip?>" name="email">
</div>
</div>
</div>
</div><br><br><br><br><br><br><br>
<div class="container">
<div class="row"><br><br>
<div class="col-xs-3" style="width: 329px;">
<div class="form-group">
<label for="email"><b>Employer (2)</b></label>
<input type="text" class="form-control" id="email" value="<?=$employer2_name?>" name="email">
</div>
</div>
<div class="col-xs-3" style="width: 291px;">
<div class="form-group">
<label for="email">Job title</label>
<input type="text" class="form-control" id="email" value="<?=$employer2_job_title?>" name="email">
</div>
</div>
<div class="col-xs-3">
<div class="form-group">
<label for="email">Dates employed</label>
<input type="text" class="form-control" id="email" value="<?=$employer2_dates?>" name="email">
</div>
</div>
</div>
</div><br><br><br>
<div class="container">
<div class="row"><br><br><br>
<div class="col-xs-3" style="width: 329px;">
<div class="form-group">
<label for="email">Work phone</label>
<input type="text" class="form-control" id="email" value="<?=$employer2_work_phone?>" name="email">
</div>
</div>
<div class="col-xs-3" style="width: 291px;">
<div class="form-group">
<label for="email">Starting pay rate</label>
<input type="text" class="form-control" id="email" value="<?=$employer2_starting_pay_rate?>" name="email">
</div>
</div>
<div class="col-xs-3">
<div class="form-group">
<label for="email">Ending pay rate</label>
<input type="text" class="form-control" id="email" value="<?=$employer2_ending_pay_rate?>" name="email">
</div>
</div>
</div>
</div><br><br><br><br><br>
<div class="container">
<div class="row"><br><br>
<div class="col-xs-3" style="width: 329px;">
<div class="form-group">
<label for="email">Address</label>
<input type="text" class="form-control" id="email" value="<?=$employer2_address?>" name="email">
</div>
</div>
<div class="col-xs-3" style="width: 125px;">
<div class="form-group">
<label for="email">City</label>
<input type="text" class="form-control" id="email" value="<?=$employer2_city?>" name="email">
</div>
</div>
<div class="col-xs-3" style="width: 136px;">
<div class="form-group">
<label for="email">State</label>
<input type="text" class="form-control" id="email" value="<?=$employer2_state?>" name="email">
</div>
</div>
<div class="col-xs-3">
<div class="form-group">
<label for="email">Zip</label>
<input type="text" class="form-control" id="email" value="<?=$employer2_zip?>" name="email">
</div>
</div>
</div>
</div><br><br><br><br><br>
<div class="container">
<div class="row"><br><br><br><br><br><br>
<div class="col-xs-3" style="width: 329px;">
<div class="form-group">
<label for="email"><b>Employer (3)</b></label>
<input type="text" class="form-control" id="email" value="<?=$employer3_name?>" name="email">
</div>
</div>
<div class="col-xs-3" style="width: 291px;">
<div class="form-group">
<label for="email">Job title</label>
<input type="text" class="form-control" id="email" value="<?=$employer3_job_title?>" name="email">
</div>
</div>
<div class="col-xs-3">
<div class="form-group">
<label for="email">Dates employed</label>
<input type="text" class="form-control" id="email" value="<?=$employer3_dates_employed?>" name="email">
</div>
</div>
</div>
</div><br><br><br>
<div class="container">
<div class="row"><br><br><br>
<div class="col-xs-3" style="width: 329px;">
<div class="form-group">
<label for="email">Work phone</label>
<input type="text" class="form-control" id="email" value="<?=$employer3_work_phone?>" name="email">
</div>
</div>
<div class="col-xs-3" style="width: 291px;">
<div class="form-group">
<label for="email">Starting pay rate</label>
<input type="text" class="form-control" id="email" value="<?=$employer3_starting_pay_rate?>" name="email">
</div>
</div>
<div class="col-xs-3">
<div class="form-group">
<label for="email">Ending pay rate</label>
<input type="text" class="form-control" id="email" value="<?=$employer3_ending_pay_rate?>" name="email">
</div>
</div>
</div>
</div><br><br><br>
<div class="container">
<div class="row"><br><br><br><br>
<div class="col-xs-3" style="width: 329px;">
<div class="form-group">
<label for="email">Address</label>
<input type="text" class="form-control" id="email" value="<?=$employer3_address?>" name="email">
</div>
</div>
<div class="col-xs-3" style="width: 125px;">
<div class="form-group">
<label for="email">City</label>
<input type="text" class="form-control" id="email" value="<?=$employer3_city?>" name="email">
</div>
</div>
<div class="col-xs-3" style="width: 136px;">
<div class="form-group">
<label for="email">State</label>
<input type="text" class="form-control" id="email" value="<?=$employer3_state?>" name="email">
</div>
</div>
<div class="col-xs-3">
<div class="form-group">
<label for="email">Zip</label>
<input type="text" class="form-control" id="email" value="<?=$employer3_zip?>" name="email">
</div>
</div>
</div>
</div><br><br><br><br><br><br><br>
<div class="container">
<div class="row"><br><br>
<div class="col-xs-3" style="width: 329px;">
<div class="form-group">
<label for="email"><b>Employer (4)</b></label>
<input type="text" class="form-control" id="email" value="<?=$employer4_name?>" name="email">
</div>
</div>
<div class="col-xs-3" style="width: 291px;">
<div class="form-group">
<label for="email">Job title</label>
<input type="text" class="form-control" id="email" value="<?=$employer4_job_title?>" name="email">
</div>
</div>
<div class="col-xs-3">
<div class="form-group">
<label for="email">Dates employed</label>
<input type="text" class="form-control" id="email" value="<?=$employer4_dates_employed?>" name="email">
</div>
</div>
</div>
</div><br><br><br>
<div class="container">
<div class="row"><br><br><br>
<div class="col-xs-3" style="width: 329px;">
<div class="form-group">
<label for="email">Work phone</label>
<input type="text" class="form-control" id="email" value="<?=$employer4_work_phone?>" name="email">
</div>
</div>
<div class="col-xs-3" style="width: 291px;">
<div class="form-group">
<label for="email">Starting pay rate</label>
<input type="text" class="form-control" id="email" value="<?=$employer4_starting_pay_rate?>" name="email">
</div>
</div>
<div class="col-xs-3">
<div class="form-group">
<label for="email">Ending pay rate</label>
<input type="text" class="form-control" id="email" value="<?=$employer4_ending_pay_rate?>" name="email">
</div>
</div>
</div>
</div><br><br><br>
<div class="container">
<div class="row"><br><br><br><br>
<div class="col-xs-3" style="width: 329px;">
<div class="form-group">
<label for="email">Address</label>
<input type="text" class="form-control" id="email" value="<?=$employer4_address?>" name="email">
</div>