{global_header_before_title}
{preload_replace:widget_bundle="frontpage"}
{embed="embeds/global_header" page="login_sequences"}

 
 <div id="columns"> 
        <div class="fts_confirm_registration_twelve"> 
            <div class="box-wrap">
                  <h1 class="title underline">Step 3 - Confirm your professional details</h1>
                  <p>Please confirm your professional details. This information is used by the Your Dentist Find-a-Dentist</p>
                  <p>website to help patients locate you and your practice.</p>
                                    
                  <div class="box-wrap-content" >
                       [##if '[##message##]' != '' ##]
                         <p class="alert">[##message##]</p>
                       [##/if##]
                       <p class="alert" id="message"></p>
                       <form name="fts_confirm_registration_twelve" method="post" action="{site_url}">
                           <input type="hidden" name="ACT" value="[##AID##]"/>
                           <input type="hidden" name="CID" value="[##CID##]"/>
                           <input type="hidden" name="cmd" id="cmd" value="" />
                           <div class="container">
                                <div class="item main-item clearer">
                                    <label>Employment Status<em>*</em></label>
                                    <select id="employ_type" name="employ_type">
                                        [##employ_type_html##]
                                    </select>
                                </div>
                                
                                <div class="item main-item clearer">
                                    <label>DCNZ Registration Number<em>*</em></label>
                                    <select name="rego_no_nz_prefix" id="rego_no_nz_prefix">
                                        [##rego_no_nz_html##]
                                    </select>
                                    <input type="text" name="rego_no_nz" id="rego_no_nz" value="[##rego_no_nz##]" maxlength="4" size="5">
                                </div>
                                
                                <div class="item main-item clearer">
                                    <label>Year Graduated<em>*</em></label>
                                    <select id="year_grad" name="year_grad">
                                        [##year_grad_html##]
                                    </select>
                                </div>
                                
                                 <div class="item main-item clearer">
                                    <label>Qualifications<br/>(Max 150 Characters)</label>
                                    <span class="quals">
                                        <textarea id="quals" name="quals" cols="30" rows="5" maxlength="150">[##quals##]</textarea>
                                        <br/>
                                        <input readonly="readonly" id="quals_max"/>
                                        <br/><br/>
                                        <p>You can enter details of your qualifications, such as a BDS, above
                                        and these will be displayed on the Your Dentist find-a-dentist
                                        website. Note: There is room to enter your biography elsewhere in
                                        this facility.
                                        </p>
                                    </span>
                                </div>
                                
                                <div class="item actions clearer">
                                    <span class="f-right">
                                        <input type="button" class="btn-back" onclick="javascript:jQuery('#cmd').val('back');jQuery('form').submit();" name="back" id="back" value="">
                                        &nbsp;&nbsp;
                                        <input type="submit" class="btn-confirm" name="confirm" id="confirm" value="">
                                    </span>
                                </div>
                           </div>    
                       </form>
                       <script type="text/javascript">
                       
                       jQuery(document).ready(function($){
                           var alertObj = $('#message');
                           alertObj.hide();

                           var quals = $('#quals').val();
                           $('#quals_max').val(quals.length + '/150');
                           
                           $('#quals').bind('keyup change', function(event){
                              var quals = $('#quals').val();
                              $('#quals_max').val(quals.length + '/150'); 
                           }); 

                           $('#confirm').click(function(){
                              
                              var pattern = new RegExp(/^[0-9]{4}$/i);
                              var rego_no = $('#rego_no_nz').val();
                              
                              if(rego_no == '' || !pattern.test(rego_no)){
                                  alertObj.html("Your Registration Number must contain 4 digits.");
                                  alertObj.show();
                                  return false;
                              } 
                               
                              $('#cmd').val('confirm'); 
                              alertObj.hide();
                              return true;
                           });
                       });
                       </script>
                  </div>
                  
            </div>
 
        </div> <!--/col1--> 
 
{global_footer}