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form.html
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<!DOCTYPE html>
<html lang="en" dir="ltr">
<head>
<meta charset="utf-8">
<title>Complaint form</title>
<link rel="stylesheet" href="css/style.css">
<link rel="icon" href="favicon.ico">
<link id="u-theme-google-font" rel="stylesheet" href="https://fonts.googleapis.com/css?family=Roboto:100,100i,300,300i,400,400i,500,500i,700,700i,900,900i|Open+Sans:300,300i,400,400i,500,500i,600,600i,700,700i,800,800i">
<link rel="stylesheet" href="/nicepage.css?version=4902aa89-ea19-4b40-af5b-7282e16729ae" media="screen">
</head>
<body>
<script src="https://cdn01.jotfor.ms/static/prototype.forms.js" type="text/javascript"></script>
<script src="https://cdn02.jotfor.ms/static/jotform.forms.js?3.3.33193" type="text/javascript"></script>
<script src="https://cdn03.jotfor.ms/js/vendor/jquery-1.8.0.min.js?v=3.3.33193" type="text/javascript"></script>
<script defer src="https://cdn01.jotfor.ms/js/vendor/maskedinput.min.js?v=3.3.33193" type="text/javascript"></script>
<script defer src="https://cdn02.jotfor.ms/js/vendor/jquery.maskedinput.min.js?v=3.3.33193" type="text/javascript"></script>
<script defer src="https://cdnjs.cloudflare.com/ajax/libs/punycode/1.4.1/punycode.js"></script>
<script type="text/javascript"> JotForm.newDefaultTheme = true;
JotForm.extendsNewTheme = false;
JotForm.newPaymentUIForNewCreatedForms = false;
JotForm.newPaymentUI = true;
JotForm.init(function(){
/*INIT-START*/
JotForm.calendarMonths = ["January","February","March","April","May","June","July","August","September","October","November","December"];
JotForm.calendarDays = ["Sunday","Monday","Tuesday","Wednesday","Thursday","Friday","Saturday","Sunday"];
JotForm.calendarOther = {"today":"Today"};
var languageOptions = document.querySelectorAll('#langList li');
for(var langIndex = 0; langIndex < languageOptions.length; langIndex++) {
languageOptions[langIndex].on('click', function(e) { setTimeout(function(){ JotForm.setCalendar("3", false, {"days":{"monday":true,"tuesday":true,"wednesday":true,"thursday":true,"friday":true,"saturday":true,"sunday":true},"future":true,"past":true,"custom":false,"ranges":false,"start":"","end":""}); }, 0); });
}
JotForm.onTranslationsFetch(function() { JotForm.setCalendar("3", false, {"days":{"monday":true,"tuesday":true,"wednesday":true,"thursday":true,"friday":true,"saturday":true,"sunday":true},"future":true,"past":true,"custom":false,"ranges":false,"start":"","end":""}); });
JotForm.formatDate({date:(new Date()), dateField:$("id_"+3)});
JotForm.displayLocalTime("input_3_hourSelect", "input_3_minuteSelect","input_3_ampm", "input_3_timeInput", false);
if (window.JotForm && JotForm.accessible) $('input_4').setAttribute('tabindex',0);
setTimeout(function() {
$('input_5').hint('ex: [email protected]');
}, 20);
if (window.JotForm && JotForm.accessible) $('input_7').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_8').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_9').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_11').setAttribute('tabindex',0);
/*INIT-END*/
});
JotForm.prepareCalculationsOnTheFly([null,{"name":"clickTo","qid":"1","text":"We are here to assist you!","type":"control_head"},{"name":"submit","qid":"2","text":"Send","type":"control_button"},{"name":"dateOf","qid":"3","text":"Date of filling the form:","type":"control_datetime"},{"name":"anySpecific","qid":"4","text":"Any Specific Area:","type":"control_textbox"},{"name":"email5","qid":"5","subLabel":"[email protected]","text":"E-mail","type":"control_email"},null,{"name":"theComplaint","qid":"7","text":"The complaint is regarding:","type":"control_textarea"},{"name":"theAddress","qid":"8","text":"The Address of complaint:","type":"control_textarea"},{"name":"nameOf9","qid":"9","text":"Name of the company\u002Fperson against which\u002Fwhom the complaint is filed:","type":"control_textbox"},null,{"name":"theSpecific","qid":"11","text":"The specific details of the complaint:","type":"control_textarea"}]);
setTimeout(function() {
JotForm.paymentExtrasOnTheFly([null,{"name":"clickTo","qid":"1","text":"We are here to assist you!","type":"control_head"},{"name":"submit","qid":"2","text":"Send","type":"control_button"},{"name":"dateOf","qid":"3","text":"Date of filling the form:","type":"control_datetime"},{"name":"anySpecific","qid":"4","text":"Any Specific Area:","type":"control_textbox"},{"name":"email5","qid":"5","subLabel":"[email protected]","text":"E-mail","type":"control_email"},null,{"name":"theComplaint","qid":"7","text":"The complaint is regarding:","type":"control_textarea"},{"name":"theAddress","qid":"8","text":"The Address of complaint:","type":"control_textarea"},{"name":"nameOf9","qid":"9","text":"Name of the company\u002Fperson against which\u002Fwhom the complaint is filed:","type":"control_textbox"},null,{"name":"theSpecific","qid":"11","text":"The specific details of the complaint:","type":"control_textarea"}]);}, 20);
</script>
<style type="text/css">@media print{.form-section{display:inline!important}.form-pagebreak{display:none!important}.form-section-closed{height:auto!important}.page-section{position:initial!important}}</style>
<link type="text/css" rel="stylesheet" href="https://cdn01.jotfor.ms/themes/CSS/5e6b428acc8c4e222d1beb91.css?themeRevisionID=5f7ed99c2c2c7240ba580251"/>
<link type="text/css" rel="stylesheet" href="https://cdn02.jotfor.ms/css/styles/payment/payment_styles.css?3.3.33193" />
<link type="text/css" rel="stylesheet" href="https://cdn03.jotfor.ms/css/styles/payment/payment_feature.css?3.3.33193" />
<style type="text/css" id="form-designer-style">
</style>
<form class="jotform-form" action="https://submit.jotform.com/submit/221313770892456/" method="post" name="form_221313770892456" id="221313770892456" accept-charset="utf-8" autocomplete="on">
<input type="hidden" name="formID" value="221313770892456" />
<input type="hidden" id="JWTContainer" value="" />
<input type="hidden" id="cardinalOrderNumber" value="" />
<div role="main" class="form-all">
<div class="formLogoWrapper Center">
<img loading="lazy" class="formLogoImg" src="images\road-safety-icon-design-with-highway-turn-vector-17425926 (1).jpg" height="140" width="140">
</div>
<style>
.formLogoWrapper { display:inline-block; position: absolute; width: 100%;} .form-all:before { background: none !important;} .formLogoWrapper.Center { top: -150px; text-align: center;}
</style>
<ul class="form-section page-section">
<li id="cid_1" class="form-input-wide" data-type="control_head">
<div class="form-header-group header-large">
<div class="header-text httal htvam">
<h1 id="header_1" class="form-header" data-component="header">
We are here to assist you!
</h1>
<div id="subHeader_1" class="form-subHeader">
Please send us details about the incident you would like to report. Our Complaint Center will analyze your complaint and take the appropriate measures in order that the reported situation will not occur at any other time in the future.
</div>
</div>
</div>
</li>
<div class="mainform">
<form name = "google-sheets">
</div>
<div class="header">
<hr />
</div>
<div class="form-group">
<label for="fname"><b>First Name:</b></label>
<input type="text" class="form-control" id="fname" placeholder="Enter first name" name="fname">
</div>
<br>
<div class="form-group">
<label for="lname"><b>Last Name:</b></label>
<input type="text" class="form-control" id="lname" placeholder="Enter last name" name="lname">
</div>
<div class="form-group">
<label for="phoneNo"> <b>Phone Number: </b> </label>
<input type="text" id="phone" class="form-control" placeholder="Enter Phone Number" name="phoneNo">
</div>
<div class="area">
<label for="Select Your Area"><b>Select Your Area</b></label>
<select id="area" name="area">
<option value="----">----</option>
<option value="North">Sadar Bazar, North Delhi</option>
<option value="North">Kashmiri Gate, North Delhi</option>
<option value="North">Darai Ganj, North Delhi</option>
<option value="North">Ashok Vihar, North Delhi</option>
<option value="North">Civil Lines, North Delhi</option>
<option value="East">Laxmi Nagar, East Delhi</option>
<option value="East">Shakarpur, East Delhi</option>
<option value="East">Anand Vihar, East Delhi</option>
<option value="East">Geeta Colony, East Delhi</option>
<option value="East">Preet Vihar, East Delhi</option>
<option value="West">Patel Nagar, West Delhi</option>
<option value="West">Rohini, West Delhi</option>
<option value="West">Rajouri Garden, West Delhi</option>
<option value="West">Punjabi Bagh, West Delhi</option>
<option value="West">Jankpuri, West Delhi</option>
<option value="West">Dwarka, West Delhi</option>
<option value="South"> Kalkaji, South Delhi</option>
<option value="South"> Defense Colony, South Delhi</option>
<option value="South"> Hauz Khas, South Delhi</option>
<option value="South"> Pushp Vihar, South Delhi</option>
<option value="South"> Badarpur, South Delhi</option>
<option value="NCR">Noida, Delhi NCR</option>
<option value="NCR">Faridabad, Delhi NCR</option>
<option value="NCR">Rohtak, Delhi NCR</option>
<option value="NCR">Gurgaon, Delhi NCR</option>
<option value="NCR">Faridabad, Delhi NCR</option>
<option value="other">Any other specific region</option>
</select>
</div>
<li class="form-line" data-type="control_textbox" id="id_4">
<label class="form-label form-label-top form-label-auto" id="label_4" for="input_4"> Any Specific Area: </label>
<div id="cid_4" class="form-input-wide" data-layout="half">
<input type="text" id="input_4" name="q4_anySpecific" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" value="" placeholder=" " data-component="textbox" aria-labelledby="label_4" />
</div>
<li class="form-line" data-type="control_datetime" id="id_3">
<label class="form-label form-label-top form-label-auto" id="label_3" for="lite_mode_3"> Date of filling the form: </label>
<div id="cid_3" class="form-input-wide" data-layout="half">
<div data-wrapper-react="true">
<div style="display:none">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="month_3" name="DateOf[month]" size="2" data-maxlength="2" data-age="" maxLength="2" value="04" autoComplete="section-input_3 off"
aria-labelledby="label_3 sublabel_3_month" />
<span class="date-separate" aria-hidden="true">
-
</span>
<label class="form-sub-label" for="month_3" id="sublabel_3_month" style="min-height:13px" aria-hidden="false"> Month </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="currentDate form-textbox validate[limitDate]" id="day_3" name="DateOf[month]" size="2" data-maxlength="2" data-age="" maxLength="2" value="26" autoComplete="section-input_3 off"
aria-labelledby="label_3 sublabel_3_day" />
<span class="date-separate" aria-hidden="true">
-
</span>
<label class="form-sub-label" for="day_3" id="sublabel_3_day" style="min-height:13px" aria-hidden="false"> Day </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="year_3" name="DateOf[year]" size="4" data-maxlength="4" data-age="" maxLength="4" value="2022" autoComplete="section-input_3 off"
aria-labelledby="label_3 sublabel_3_year" />
<label class="form-sub-label" for="year_3" id="sublabel_3_year" style="min-height:13px" aria-hidden="false"> Year </label>
</span>
</div>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" class="form-textbox validate[limitDate, validateLiteDate]" id="lite_mode_3" size="12" data-maxlength="12" maxLength="12" data-age="" value="04-26-2022" data-format="mmddyyyy" data-seperator="-"
placeholder="MM-DD-YYYY" autoComplete="section-input_3 off" aria-labelledby="label_3 sublabel_3_litemode" />
<img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_3_pick" src="https://cdn.jotfor.ms/images/calendar.png" data-component="datetime" aria-hidden="true" data-allow-time="No" data-version="v2" />
<label class="form-sub-label" for="lite_mode_3" id="sublabel_3_litemode" style="min-height:13px" aria-hidden="false"> </label>
</span>
</div>
</div>
</li>
<div id="formsection">
<label><b>What is the category of complain you are facing?</b></label>
<p><input type="checkbox" name="section" value="sports">Road Repairing</p>
<p><input type="checkbox" name="section" value="business">Water Sewer </p>
<p><input type="checkbox" name="section" value="health">Falling electricity pole</p>
<p><input type="checkbox" name="section" value="sports">Road Blockge</p>
<p><input type="checkbox" name="section" value="sports">Any other form of local issue</p>
</div>
<li class="form-line" data-type="control_datetime" id="id_3">
<label class="form-label form-label-top form-label-auto" id="label_3" for="lite_mode_3"> Date of filling the form: </label>
<div id="cid_3" class="form-input-wide" data-layout="half">
<div data-wrapper-react="true">
<div style="display:none">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="month_3" name="DateOf[month]" size="2" data-maxlength="2" data-age="" maxLength="2" value="04" autoComplete="section-input_3 off"
aria-labelledby="label_3 sublabel_3_month" />
<span class="date-separate" aria-hidden="true">
-
</span>
<label class="form-sub-label" for="month_3" id="sublabel_3_month" style="min-height:13px" aria-hidden="false"> Month </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="currentDate form-textbox validate[limitDate]" id="day_3" name="DateOf[month]" size="2" data-maxlength="2" data-age="" maxLength="2" value="26" autoComplete="section-input_3 off"
aria-labelledby="label_3 sublabel_3_day" />
<span class="date-separate" aria-hidden="true">
-
</span>
<label class="form-sub-label" for="day_3" id="sublabel_3_day" style="min-height:13px" aria-hidden="false"> Day </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="year_3" name="DateOf[year]" size="4" data-maxlength="4" data-age="" maxLength="4" value="2022" autoComplete="section-input_3 off"
aria-labelledby="label_3 sublabel_3_year" />
<label class="form-sub-label" for="year_3" id="sublabel_3_year" style="min-height:13px" aria-hidden="false"> Year </label>
</span>
</div>
<span class="form-sub-label-container" style="vertical-align:top">
<input type="text" class="form-textbox validate[limitDate, validateLiteDate]" id="lite_mode_3" size="12" data-maxlength="12" maxLength="12" data-age="" value="04-26-2022" data-format="mmddyyyy" data-seperator="-"
placeholder="MM-DD-YYYY" autoComplete="section-input_3 off" aria-labelledby="label_3 sublabel_3_litemode" />
<img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_3_pick" src="https://cdn.jotfor.ms/images/calendar.png" data-component="datetime" aria-hidden="true" data-allow-time="No" data-version="v2" />
<label class="form-sub-label" for="lite_mode_3" id="sublabel_3_litemode" style="min-height:13px" aria-hidden="false"> </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_email" id="id_5">
<label class="form-label form-label-top form-label-auto" id="label_5" for="input_5"> E-mail </label>
<div id="cid_5" class="form-input-wide" data-layout="half">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="email" id="input_5" name="q5_email5" class="form-textbox validate[Email]" data-defaultvalue="" style="width:310px" size="310" value="" placeholder="ex: [email protected]" data-component="email" aria-labelledby="label_5 sublabel_input_5" />
<label class="form-sub-label" for="input_5" id="sublabel_input_5" style="min-height:13px" aria-hidden="false"> [email protected] </label>
</span>
</div>
</li>
<li class="form-line" data-type="control_textarea" id="id_7">
<label class="form-label form-label-top form-label-auto" id="label_7" for="input_7"> The complaint is regarding: </label>
<div id="cid_7" class="form-input-wide" data-layout="full">
<textarea id="input_7" class="form-textarea" name="q7_theComplaint" style="width:648px;height:163px" data-component="textarea" aria-labelledby="label_7"></textarea>
</div>
</li>
<li class="form-line" data-type="control_textarea" id="id_8">
<label class="form-label form-label-top form-label-auto" id="label_8" for="input_8"> The Address of complaint: </label>
<div id="cid_8" class="form-input-wide" data-layout="full">
<textarea id="input_8" class="form-textarea" name="q8_theAddress" style="width:648px;height:163px" data-component="textarea" aria-labelledby="label_8"></textarea>
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_9">
<label class="form-label form-label-top form-label-auto" id="label_9" for="input_9"> Name of the company/person against which/whom the complaint is filed: </label>
<div id="cid_9" class="form-input-wide" data-layout="half">
<input type="text" id="input_9" name="q9_nameOf9" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" value="" placeholder=" " data-component="textbox" aria-labelledby="label_9" />
</div>
</li>
<li class="form-line" data-type="control_textarea" id="id_11">
<label class="form-label form-label-top form-label-auto" id="label_11" for="input_11"> The specific details of the complaint: </label>
<div id="cid_11" class="form-input-wide" data-layout="full">
<textarea id="input_11" class="form-textarea" name="q11_theSpecific" style="width:648px;height:163px" data-component="textarea" aria-labelledby="label_11"></textarea>
</div>
<div class="contentarea">
<h2>
Take Photograph of the Complaint region (optional):
</h2>
<div class="camera">
<video id="video">Video stream not available.</video>
</div>
<div><button id="startbutton">Take photo</button></div>
<canvas id="canvas"></canvas>
<div class="output">
<img id="photo" alt="The screen capture will appear in this box.">
</div>
</div>
<script>
/* JS comes here */
(function() {
var width = 320; // We will scale the photo width to this
var height = 0; // This will be computed based on the input stream
var streaming = false;
var video = null;
var canvas = null;
var photo = null;
var startbutton = null;
function startup() {
video = document.getElementById('video');
canvas = document.getElementById('canvas');
photo = document.getElementById('photo');
startbutton = document.getElementById('startbutton');
navigator.mediaDevices.getUserMedia({
video: true,
audio: false
})
.then(function(stream) {
video.srcObject = stream;
video.play();
})
.catch(function(err) {
console.log("An error occurred: " + err);
});
video.addEventListener('canplay', function(ev) {
if (!streaming) {
height = video.videoHeight / (video.videoWidth / width);
if (isNaN(height)) {
height = width / (4 / 3);
}
video.setAttribute('width', width);
video.setAttribute('height', height);
canvas.setAttribute('width', width);
canvas.setAttribute('height', height);
streaming = true;
}
}, false);
startbutton.addEventListener('click', function(ev) {
takepicture();
ev.preventDefault();
}, false);
clearphoto();
}
function clearphoto() {
var context = canvas.getContext('2d');
context.fillStyle = "#AAA";
context.fillRect(0, 0, canvas.width, canvas.height);
var data = canvas.toDataURL('image/png');
photo.setAttribute('src', data);
}
function takepicture() {
var context = canvas.getContext('2d');
if (width && height) {
canvas.width = width;
canvas.height = height;
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