/home/mip/mip/app/Modules/Client/Views/directory-store/includes/form.blade.php
<input type="hidden" name="_token" value="{{ csrf_token() }}">
<div class="row">
<div class="col-md-7">
<div class="col-md-12">
<div class="form-group {{ ($errors->has('category') ? 'has-error':'') }}">
<label class="control-label col-md-3">Category: <i class="required">*</i></label>
<div class="col-md-9">
{!! Form::select('category', ['Directory' => 'Directory', 'Store' => 'Store'], null ,['class'=>'input-md form-control', 'id'=>'category']) !!}
{!! $errors->first('category', '<span class="text-red">:message</span>') !!}
</div>
</div>
<div class="form-group {{ ($errors->has('affiliate_id') ? 'has-error':'') }}" id="affiliate">
<label class="control-label col-md-3">Affiliate: <i class="required">*</i></label>
<div class="col-md-9">
<div class="input-group">
{!! Form::select('affiliate_id', ['' => '-- Select Affiliate'] + $affiliates , null , ['id'=>'selectAffiliate', 'class'=>'form-control']) !!}
<span class="input-group-btn">
<button class="btn btn-primary btn-flat" type="button" data-toggle="tooltip" title="Add Affiliate" style="cursor:pointer" onclick="doModalAddAffiliate();"><i class="fa fa-plus-circle"></i></button>
{!! $errors->first('affiliate_id', '<span class="text-red">:message</span>') !!}
</span>
</div>
</div>
</div>
<div class="form-group {{ ($errors->has('specialization_id') ? 'has-error':'') }}" id="specialization">
<label class="control-label col-md-3">Specialization:</label>
<div class="col-md-9">
<div class="input-group">
{!! Form::select('specialization_id', ['0' => '-- Select Specialization'] + $specializations , null , ['id'=>'selectSpecialization', 'class'=>'form-control']) !!}
<span class="input-group-btn">
<button class="btn btn-primary btn-flat" type="button" data-toggle="tooltip" title="Add Specialization" style="cursor:pointer" onclick="doModalAddSpecialization();"><i class="fa fa-plus-circle"></i></button>
{!! $errors->first('specialization_id', '<span class="text-red">:message</span>') !!}
</span>
</div>
</div>
</div>
<div class="form-group {{ ($errors->has('name') ? 'has-error':'') }}">
<label class="control-label col-md-3" id="nameLabel">Directory Name: <i class="required">*</i></label>
<div class="col-md-9">
{!! Form::text('name', null , ['class'=>'form-control', 'placeholder'=>'Enter Directory Name', 'autocomplete'=>'off', 'id'=>'name']) !!}
{!! $errors->first('name', '<span class="text-red">:message</span>') !!}
</div>
</div>
<div class="form-group {{ ($errors->has('tel_no') ? 'has-error':'') }}">
<label class="control-label col-md-3">Telephone no.: <i class="required">*</i></label>
<div class="col-md-9">
{!! Form::text('tel_no', null , ['class'=>'form-control', 'placeholder'=>'Enter telephone number', 'autocomplete'=>'off']) !!}
{!! $errors->first('tel_no', '<span class="text-red">:message</span>') !!}
</div>
</div>
<div class="form-group {{ ($errors->has('email') ? 'has-error':'') }}" id="email">
<label class="control-label col-md-3">Email:</label>
<div class="col-md-9">
{!! Form::email('email', null , ['class'=>'form-control', 'placeholder'=>'Enter Email Address', 'autocomplete'=>'off']) !!}
{!! $errors->first('email', '<span class="text-red">:message</span>') !!}
</div>
</div>
<div class="form-group">
<label class="control-label col-md-3" id="address">Address: <i class="required">*</i></label>
<div class="col-md-9">
{!! Form::text('address_number', null , ['class'=>'form-control', 'placeholder'=>'Address #', 'autocomplete'=>'off']) !!}
</div>
</div>
<div class="form-group">
<div class="col-md-3"></div>
<div class="col-md-4">
{!! Form::text('street', null , ['class'=>'form-control', 'placeholder'=>'Street', 'autocomplete'=>'off']) !!}
{!! $errors->first('street', '<span class="text-red">:message</span>') !!}
</div>
<div class="col-md-4">
{!! Form::text('barangay', null , ['class'=>'form-control', 'placeholder'=>'Barangay', 'autocomplete'=>'off']) !!}
{!! $errors->first('barangay', '<span class="text-red">:message</span>') !!}
</div>
</div>
<div class="form-group {{ ($errors->has('city_id') ? 'has-error':'') }}">
<label class="control-label col-md-3">City:</label>
<div class="col-md-9">
{!! Form::select('city_id', ['0' => '-- Select City'] + $cities , null , ['class'=>'form-control']) !!}
{!! $errors->first('city_id', '<span class="text-red">:message</span>') !!}
</div>
</div>
<div class="form-group {{ ($errors->has('municipality_id') ? 'has-error':'') }}">
<label class="control-label col-md-3">Municipality:</label>
<div class="col-md-9">
{!! Form::select('municipality_id', ['0' => '-- Select Municipality'] + $municipalities , null , ['class'=>'form-control']) !!}
{!! $errors->first('municipality_id', '<span class="text-red">:message</span>') !!}
</div>
</div>
<div class="form-group {{ ($errors->has('province_id') ? 'has-error':'') }}">
<label class="control-label col-md-3" id="province">Province: <i class="required">*</i></label>
<div class="col-md-9">
{!! Form::select('province_id', ['' => '-- Select Province'] + $provinces , null , ['class'=>'form-control']) !!}
{!! $errors->first('province_id', '<span class="text-red">:message</span>') !!}
</div>
</div>
<div class="form-group {{ ($errors->has('zip_code') ? 'has-error':'') }}">
<label class="control-label col-md-3">Zip Code:</label>
<div class="col-md-9">
{!! Form::text('zip_code', null , ['class'=>'form-control', 'autocomplete'=>'off']) !!}
{!! $errors->first('zip_code', '<span class="text-red">:message</span>') !!}
</div>
</div>
<div class="form-group {{ $errors->has('details') ? ' has-error' : '' }}">
<label class="control-label col-md-3" id="details">Details: <i class="required">*</i></label>
<div class="col-md-9">
{!! Form::textarea('details', null , ['class'=>'form-control wysihtml5', 'placeholder'=>'Details here...', 'autocomplete'=>'off']) !!}
{!! $errors->first('details', '<span class="text-red">:message</span>') !!}
</div>
</div>
</div>
</div>
<div class="col-md-5">
<div class="col-md-12">
<div class="panel panel-default">
<div class="panel-heading">Location</div>
<div class="panel-body">
<div class="form-group">
<input id="search" type="text" placeholder="Search.." style="width: 150px; height: 30px; margin-top: 10px;">
<div id="map" style="width: 100%; height: 250px;"></div>
</div>
<div class="form-group {{ ($errors->has('lat') ? 'has-error':'') }}">
<label class="control-label col-md-4">Latitude: <i class="required">*</i></label>
<div class="col-md-8">
{!! Form::text('lat', null , ['class'=>'form-control', 'id'=>'lat', 'autocomplete'=>'off']) !!}
{!! $errors->first('lat', '<span class="text-red">:message</span>') !!}
</div>
</div>
<div class="form-group {{ ($errors->has('lng') ? 'has-error':'') }}">
<label class="control-label col-md-4">Longitude: <i class="required">*</i></label>
<div class="col-md-8">
{!! Form::text('lng', null , ['class'=>'form-control', 'id'=>'lng', 'autocomplete'=>'off']) !!}
{!! $errors->first('lng', '<span class="text-red">:message</span>') !!}
</div>
</div>
</div>
</div>
</div>
</div>
</div>