86 lines
3.0 KiB
HTML
86 lines
3.0 KiB
HTML
<!DOCTYPE html>
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<html lang="en">
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<head>
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<meta charset="UTF-8">
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<meta name="viewport" content="width=device-width, initial-scale=1">
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<link href="style.css" rel="stylesheet" />
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</head>
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<body>
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<form>
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<label class="item">
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<span class="fh">Enable autofill</span>
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<input name="enable" id="enable" type="checkbox" />
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</label>
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<label class="item">
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<span class="fh">Your BahnCard 100 number</span><br />
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<span class="sh">The number on the front of your card starting with <span class="ms">7081</span>.</span><br>
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<input name="bcnum" id="bcnum" type="text" pattern="70814[0-9]{11}" required
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title="Your BahnCard number is 16 digits long and starts with 7081." />
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<button id="bcnum-get-from-profile">Get from profile (experimental)</button>
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</label>
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<label class="item">
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<span class="fh">Your date of birth</span><br>
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<input name="birthday" id="birthday" type="date" required />
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</label>
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<label class="item">
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<span class="fh">Skip questionnaire</span><br>
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<span class="sh">Automatically answer "I was delayed, by more than 60 minutes."</span><br>
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<input name="autocontinue" id="autocontinue" type="checkbox" />
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</label>
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<fieldset>
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<legend>Address data</legend>
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<label class="item">
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<span class="fh">Title</span>
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<select name="title" id="title">
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<option value="">Please choose</option>
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<option value="mr">Mr</option>
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<option value="ms">Ms</option>
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</select>
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</label>
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<label class="item">
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<span class="fh">Name</span><br>
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<input name="firstname" id="firstname" />
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</label>
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<label class="item">
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<span class="fh">Surname</span><br>
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<input name="surname" id="surname" />
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</label>
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<label class="item">
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<span class="fh">Email address</span><br>
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<input name="email" id="email" type="email" />
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</label>
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<label class="item">
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<span class="fh">Street address</span><br>
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<input name="addr1" id="addr1" placeholder="e.g. Hauptstraße 1a">
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</label>
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<label class="item">
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<span class="fh">Postcode</span><bR>
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<input name="postcode" id="postcode" />
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</label>
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<label class="item">
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<span class="fh">Place</span><br>
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<input name="placename" id="placename" />
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</label>
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</fieldset>
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<fieldset>
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<legend>Bank details</legend>
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<label class="item">
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<span class="fh">IBAN</span><br>
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<span class="sh">Please make sure to enter any letters in upper case.</span><br>
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<input name="iban" id="iban" pattern="[A-Z]{2}\d{2}[A-Z0-9]+" />
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</label>
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<label class="item">
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<span class="fh">BIC</span><br>
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<span class="sh">Bank Identifier Code for your bank. Can mostly be omitted.</span><br>
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<input name="bic" id="bic" />
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</label>
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</fieldset>
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<div class="item"><button type="submit">Save</button><span id="success"></span></div>
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<p id="errors"></p>
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</form>
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<script src="script.js"></script>
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</body>
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</html> |