<link href="//netdna.bootstrapcdn.com/bootstrap/3.0.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css">
<script src="//netdna.bootstrapcdn.com/bootstrap/3.0.0/js/bootstrap.min.js"></script>
<script src="//code.jquery.com/jquery-1.11.1.min.js"></script>
<!------ Include the above in your HEAD tag ---------->
<div class="container">
<div class="row">
<div class="col-xs-12 col-sm-8 col-md-6 col-sm-offset-2 col-md-offset-3">
<form role="form">
<h2> <small>Register for Wholesale Pricing</small></h2>
<hr class="colorgraph">
<div class="form-group">
<input type="text" name="name" id="name" class="form-control input-lg" placeholder="Company Name" tabindex="3">
</div>
<div class="row">
<div class="col-xs-6 col-sm-6 col-md-6">
<div class="form-group">
<input type="text" name="fname" id="fname" class="form-control input-lg" placeholder="Contact First Name" tabindex="1">
</div>
</div>
<div class="col-xs-6 col-sm-6 col-md-6">
<div class="form-group">
<input type="text" name="lname" id="lname" class="form-control input-lg" placeholder="Last Name" tabindex="2">
</div>
</div>
<div class="col-xs-6 col-sm-6 col-md-6">
<div class="form-group">
<input type="text" name="taxid" id="taxid" class="form-control input-lg" placeholder="Tax ID" tabindex="1">
</div>
</div>
<div class="col-xs-6 col-sm-6 col-md-6">
<div class="form-group">
<input type="text" name="phone" id="phone" class="form-control input-lg" placeholder="Contact Number" tabindex="2">
</div>
</div>
<div class="col-xs-8 col-sm-8 col-md-8">
<div class="form-group">
<select id="industry" name="industry" class="form-control input-lg" tabindex="2">
<option value="">Type of Business</option>
<option>Airport/Airline</option>
<option>Hotel/Lodging</option>
<option>Luxury Travel</option>
<option>Restaurant/Cafe</option>
<option>Vending/Distribution</option>
</select>
</div>
</div>
</div>
<div class="form-group">
<input type="email" name="email" id="email" class="form-control input-lg" placeholder="Email" tabindex="4"><div class="form-group">
</div>
<input type="text" name="street" id="street" class="form-control input-lg" placeholder="Street Address" tabindex="3">
</div>
<div class="row">
<div class="col-xs-8 col-sm-8 col-md-8">
<div class="form-group">
<input type="text" name="town" id="town" class="form-control input-lg" placeholder="City or Town" tabindex="2">
</div>
</div>
<div class="col-xs-4 col-sm-4 col-md-4">
<div class="form-group">
<select id="curso" name="curso" class="form-control input-lg" tabindex="2">
<option value="">Select State</option>
<option value="AL">AL</option>
<option value="AK">AK</option>
<option value="AR">AR</option>
<option value="AZ">AZ</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NC">NC</option>
<option value="NE">NE</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="ND">ND</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VT">VT</option>
<option value="VA">VA</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
</select>
</div>
</div>
</div>
<div class="row">
<div class="col-xs-6 col-sm-6 col-md-6">
<div class="form-group">
<input type="text" name="zip" id="zip" class="form-control input-lg" placeholder="Zip Code" tabindex="2">
</div>
</div>
<div class="col-xs-6 col-sm-6 col-md-6">
<div class="form-group">
<input type="text" name="usa" id="usa" class="form-control input-lg" placeholder="United States" tabindex="2">
</div>
</div>
<div class="col-xs-6 col-sm-6 col-md-6">
<div class="form-group">
<input type="password" name="password" id="password" class="form-control input-lg" placeholder="Password" tabindex="5">
</div>
</div>
<div class="col-xs-6 col-sm-6 col-md-6">
<div class="form-group">
<input type="password" name="password_confirmation" id="password_confirmation" class="form-control input-lg" placeholder="Confirm Password" tabindex="6">
</div>
</div>
</div>
</br>
</br>
<div class="row">
<div class="col-xs-3 col-sm-3 col-md-3">
<span class="button-checkbox">
<button type="button" class="btn" data-color="info" tabindex="7">I Agree</button>
<input type="checkbox" name="t_and_c" id="t_and_c" class="hidden" value="1">
</span>
</div>
<div class="col-xs-9 col-sm-9 col-md-9">
By clicking <strong class="label label-primary">Register</strong>, you certify that you either work for or own the company that you are registering and that you have been given the authorization to order products on their behalf.
</div>
</div>
<hr class="colorgraph">
<div class="row">
<div class="col-xs-6 col-md-6"><input type="submit" value="Register" class="btn btn-primary btn-block btn-lg" tabindex="7"></div>
<div class="col-xs-6 col-md-6"><a href="#" class="btn btn-success btn-block btn-lg">Sign In</a></div>
</div>
</form>
</div>
</div>
<!-- Modal -->
<div class="modal fade" id="t_and_c_m" tabindex="-1" role="dialog" aria-labelledby="myModalLabel" aria-hidden="true">
<div class="modal-dialog">
<div class="modal-content">
<div class="modal-header">
<button type="button" class="close" data-dismiss="modal" aria-hidden="true">×</button>
<h4 class="modal-title" id="myModalLabel">Terms & Conditions</h4>
</div>
<div class="modal-body">
<p>Lorem ipsum dolor sit amet, consectetur adipisicing elit. Similique, itaque, modi, aliquam nostrum at sapiente consequuntur natus odio reiciendis perferendis rem nisi tempore possimus ipsa porro delectus quidem dolorem ad.</p>
<p>Lorem ipsum dolor sit amet, consectetur adipisicing elit. Similique, itaque, modi, aliquam nostrum at sapiente consequuntur natus odio reiciendis perferendis rem nisi tempore possimus ipsa porro delectus quidem dolorem ad.</p>
<p>Lorem ipsum dolor sit amet, consectetur adipisicing elit. Similique, itaque, modi, aliquam nostrum at sapiente consequuntur natus odio reiciendis perferendis rem nisi tempore possimus ipsa porro delectus quidem dolorem ad.</p>
<p>Lorem ipsum dolor sit amet, consectetur adipisicing elit. Similique, itaque, modi, aliquam nostrum at sapiente consequuntur natus odio reiciendis perferendis rem nisi tempore possimus ipsa porro delectus quidem dolorem ad.</p>
<p>Lorem ipsum dolor sit amet, consectetur adipisicing elit. Similique, itaque, modi, aliquam nostrum at sapiente consequuntur natus odio reiciendis perferendis rem nisi tempore possimus ipsa porro delectus quidem dolorem ad.</p>
<p>Lorem ipsum dolor sit amet, consectetur adipisicing elit. Similique, itaque, modi, aliquam nostrum at sapiente consequuntur natus odio reiciendis perferendis rem nisi tempore possimus ipsa porro delectus quidem dolorem ad.</p>
<p>Lorem ipsum dolor sit amet, consectetur adipisicing elit. Similique, itaque, modi, aliquam nostrum at sapiente consequuntur natus odio reiciendis perferendis rem nisi tempore possimus ipsa porro delectus quidem dolorem ad.</p>
</div>
<div class="modal-footer">
<button type="button" class="btn btn-primary" data-dismiss="modal">I Agree</button>
</div>
</div><!-- /.modal-content -->
</div><!-- /.modal-dialog -->
</div><!-- /.modal -->
</div>
$(function () {
$('.button-checkbox').each(function () {
// Settings
var $widget = $(this),
$button = $widget.find('button'),
$checkbox = $widget.find('input:checkbox'),
color = $button.data('color'),
settings = {
on: {
icon: 'glyphicon glyphicon-check'
},
off: {
icon: 'glyphicon glyphicon-unchecked'
}
};
// Event Handlers
$button.on('click', function () {
$checkbox.prop('checked', !$checkbox.is(':checked'));
$checkbox.triggerHandler('change');
updateDisplay();
});
$checkbox.on('change', function () {
updateDisplay();
});
// Actions
function updateDisplay() {
var isChecked = $checkbox.is(':checked');
// Set the button's state
$button.data('state', (isChecked) ? "on" : "off");
// Set the button's icon
$button.find('.state-icon')
.removeClass()
.addClass('state-icon ' + settings[$button.data('state')].icon);
// Update the button's color
if (isChecked) {
$button
.removeClass('btn-default')
.addClass('btn-' + color + ' active');
}
else {
$button
.removeClass('btn-' + color + ' active')
.addClass('btn-default');
}
}
// Initialization
function init() {
updateDisplay();
// Inject the icon if applicable
if ($button.find('.state-icon').length == 0) {
$button.prepend('<i class="state-icon ' + settings[$button.data('state')].icon + '"></i> ');
}
}
init();
});
});
