38 lines
1.2 KiB
Plaintext
38 lines
1.2 KiB
Plaintext
<div class="row account">
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<div class="small-12 column">
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<h1 class="inline-block"><%= t('verification.residence.new.title') %></h1>
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<%= form_for @residence, as: "residence", url: residence_path do |f| %>
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<%= render 'errors' %>
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<div class="small-12 medium-6">
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<div class="small-6 medium-3">
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<%= f.select :document_type, document_types, prompt: "" %>
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</div>
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<div class="small-6 medium-8">
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<%= f.text_field :document_number %>
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</div>
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</div>
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<div class="date small-12 medium-6">
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<%= f.date_select :date_of_birth,
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prompt: true,
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start_year: 1900, end_year: 16.years.ago.year %>
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</div>
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<div class="small-12 medium-4 clear">
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<%= f.text_field :postal_code %>
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</div>
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<div class="small-12">
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<%= f.check_box :terms_of_service, label: t("verification.residence.new.accept_terms_text") %>
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<%= link_to t("verification.residence.new.accept_terms_link"), '/census_terms', target: "_blank" %>
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</div>
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<div class="small-12 clear">
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<%= f.submit "Verify" %>
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</div>
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<% end %>
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</div>
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</div> |