{% extends 'base.html' %}
{% load helper_tags %}
{% block content %}
<div class="content">
    <div class="">
        <div class="page-header-title">
        </div>
    </div>
    <div class="page-content-wrapper ">
        <div class="container">
            <div class="row">
                <div class="col-sm-12">
                    <div class="panel panel-primary">
                        <div class="panel-body">
                            <h4 class="m-t-0 m-b-0">Survey Information</h4>
                            {% if messages %}
                            {% for msg in messages %}

                        <div class="alert alert-success alert-dismissible fade in"> 
                            <button type="button" class="close" data-dismiss="alert" aria-label="Close">
                                <span aria-hidden="true">×</span>
                            </button>{{msg.message}}
                        </div>
                        
                            {% endfor %}
                            {% endif %}
                            {% if form.errors.items %} {% for field in form %} {% for error in field.errors %}
                            <div class="alert alert-danger alert-dismissible fade in">
                                <button type="button" class="close" data-dismiss="alert" aria-label="Close">
                                    <span aria-hidden="true">×</span>
                                </button>{{ error|escape }}</div>
                            {% endfor %} {% endfor %} {% for error in form.non_field_errors %}
                            <div class="alert alert-danger alert-dismissible fade in">
                                <button type="button" class="close" data-dismiss="alert" aria-label="Close">
                                    <span aria-hidden="true">×</span>
                                </button>{{ error|escape }}</div>
                            {% endfor %} {% endif %}
                            <div class="row">
                                <div class="col-sm-12 col-xs-12">
                                    <div class="m-t-20">
                                        <!-- <h4 class="m-t-0 m-b-0">Survey Information</h4> -->
                                        <form class='' name='surveyrequest' id='surveyrequest' method='POST' action='' novalidate='' enctype='multipart/form-data'>
                                            {% csrf_token %}
                                            <div class="col-sm-12 survey_b_location_other_c">
                                                <div class="row">
                                                    <div class="col-md-4">
                                                        <label>Client File No.</label>
                                                        <div class="form-group">
                                                            <input type="text" id="client_file_no" name="client_file_no" class="form-control"  placeholder="Please Enter Client File No" value="">
                                                        </div>
                                                    </div>
                                                    <div class="col-md-4">
                                                        <label>Vessel Name</label>
                                                        <div class="form-group">
                                                            <input type="text" id="vessel_name" name="vessel_name" class="form-control"  placeholder="Please Enter Vessel Name" value="">
                                                        </div>
                                                    </div>
                                                    <div class="col-md-4">
                                                        <label>Is a PO No. Required?</label>
                                                        <div class="form-group">
                                                            <input type="text" id="job_require" name="job_require" class="form-control"  placeholder="Please Enter PO Number" value="">
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                            
                                            <div class="col-sm-12 survey_b_location_other_c">

                                                <div class="row">

                                                    <div class="col-md-4">
                                                        <label>Surveyor:</label>
                                                        <div class="form-group">
                                                            <select class="form-control survey_b_location select2" name="surveyor" id="surveyor" multiple>
                                                                <option value="">Select Surveyor</option>
                                                                {% for survey in survey_request_options.Surveyor %}
                                                                    <option value="{{survey.name|capfirst}}" {% if survey_report_barge.survey|str_is_in:survey.id %} selected="selected" {% endif %}>
                                                                        {{survey.name|capfirst}}
                                                                    </option>
                                                                {% endfor %}
                                                            </select>
                                                        </div>
                                                    </div>

                                                    <div class="col-md-4">
                                                        <label>Senior Surveyor:</label>
                                                        <div class="form-group">
                                                            <select class="form-control survey_b_location" name="senior_surveyor" id="senior_surveyor" >
                                                            <option value="">Select Senior Surveyor</option>
                                                            {% for survey in survey_request_options.Surveyor %}
                                                                <option value="{{survey.name|capfirst}}" {% if survey_report_barge.survey|str_is_in:survey.id %} selected="selected" {% endif %}>
                                                                    {{survey.name|capfirst}}
                                                                </option>
                                                            {% endfor %}
                                                            </select>
                                                        </div>
                                                    </div>
                                                    <div class="col-md-4">
                                                        <label>Appraiser:</label>
                                                        <div class="form-group">
                                                            <select class="form-control survey_b_location" name="appraiser" id="appraiser">
                                                                <option value="">Select Appraiser</option>
                                                                {% for survey in survey_request_options.Appraiser %}
                                                                    <option value="{{survey.name|capfirst}}" {% if survey_report_barge.survey|str_is_in:survey.id %} selected="selected" {% endif %}>
                                                                        {{survey.name|capfirst}}
                                                                    </option>
                                                                {% endfor %}
                                                                
                                                            </select>
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                            
                                            <div class="col-sm-12 survey_b_location_other_c">
                                                <div class="row">
                                                    <div class="col-md-6">
                                                        <label>Priority Level:</label>
                                                        <div class="form-group">
                                                            <select class="form-control survey_b_location" name="priority_level" id="priority_level" >
                                                                <option value="">Select Priority Level</option>
                                                                <option value="Priority">Priority </option>
                                                                <option value="Regular" >Regular</option>
                                                            </select>
                                                        </div>
                                                    </div>
                                                    <div class="col-md-6">
                                                        <label>Due Date, Required if a Priority:</label>
                                                        <div class="form-group">
                                                        <input type="text" id="due_date" name="due_date" class="form-control datepicker"  placeholder="Please Enter Due Date" value="" > 
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="row">
                                                <!-- <div class='col-md-4 finding-check-wrapper clearfix'>
                                                    <label class="d-block col-md-12">&nbsp;</label>
                                                        <div class='col-md-1 left'>
                                                            <div class="form-group">
                                                                <div class="checkbox checkbox-primary">
                                                                <input type="checkbox" class='select_new_client' id="select_new_client" name='select_new_client' >
                                                                <label></label>
                                                                </div>
                                                            </div>
                                                        </div>
    
    
                                                        <div class='col-md-11 my_check_c right'>
                                                            <div class="form-group">
                                                                <div class="lbl-text">
                                                                    Select If New Client or info is not in Juris
                                                                </div>
                                                            </div>
                                                        </div>
    
                                                </div> -->

                                                <!----
                                                    <div class='col-md-4 finding-check-wrapper clearfix openAddClientModel'  >
                                                        <label class="d-block col-md-12">&nbsp;</label>
                                                        <div class='col-md-11 my_check_c right'>
                                                            <a href="javascript:void(0)" class="btn waves-effect waves-light">
                                                                <i class="mdi mdi-plus-circle"></i>
                                                                Add New Client or Contact
                                                            </a>
                                                        </div>
                                                    </div>
                                                -->

                                                <div class="col-md-4 survey_b_location_other_c isNotChangeRequestedBy addNewClient-btn survey-request-equest">
                                                    <div class="form-group">
                                                        <label>Requested By:
                                                            <span class="info-circle"  data-container="body" title="" data-toggle="popover" data-placement="top" data-content="This is the name of the person who reached out to DLS requesting a survey." data-original-title="" >
                                                                <i class="fa fa-info-circle text-info" aria-hidden="true"></i>
                                                            </span>
                                                        </label>
                                                       
                                                        <input type="text" id="client_new" name="client_new" class="form-control client_new_ client_new_text" required="" data-parsley-required-message="Please Enter Requested By Name" placeholder="Please Enter Requested By Name" data-value>

                                                    </div>
                                                    <div class="openAddClientModel">
                                                        <a href="javascript:void(0)" class="btn btn-link waves-effect waves-light">
                                                           <i class="mdi mdi-plus-circle"></i>
                                                           Add New Client
                                                       </a> 
                                                    </div>
                                                </div>


                                                <div class="col-md-4 survey_b_location_other_c isChangeRequestedBy addNewClient-btn survey-request-equest">
                                                    <div class="form-group">
                                                        <label>Requested By:
                                                            <span class="info-circle"  data-container="body" title="" data-toggle="popover" data-placement="top" data-content="This is the name of the person who reached out to DLS requesting a survey." data-original-title="" >
                                                                <i class="fa fa-info-circle text-info" aria-hidden="true"></i>
                                                            </span>
                                                        </label>
                                                        
                                                        <select class="form-control dropdown_client client_new_select select-current-added-client" name="client_new" id="client_new" required="" data-parsley-required-message="Please select requested by" data-value>
                                                            <option value=""  >Select Requested By</option>
                                                            {% for survey in survey_request_options.Client_New %}
                                                                <option value="{{survey.id}}">
                                                                    {{survey.nickname|capfirst}}, {{survey.address|capfirst}}, {{survey.name|capfirst}}
                                                                </option>
                                                            {% endfor %}
                                                        </select>   
                                                    </div>
                                                    <div class="openAddClientModel">
                                                        <a href="javascript:void(0)" class="btn btn-link waves-effect waves-light">
                                                            <i class="mdi mdi-plus-circle"></i>
                                                            Add New Client
                                                        </a> 
                                                    </div>
                                                </div>

                                                <div class="col-md-4 survey_b_location_other_c edit_request">
                                                    <div class="form-group">
                                                        <label>Requested By:
                                                            <span class="info-circle"  data-container="body" title="" data-toggle="popover" data-placement="top" data-content="This is the name of the person who reached out to DLS requesting a survey." data-original-title="" >
                                                                    <i class="fa fa-info-circle text-info" aria-hidden="true"></i>
                                                            </span>
                                                        </label>
                                                        <input type="text" id="client_new_checked" name="client_new_checked" class="form-control client_new client_new_checked client_new_text_ common-control-red" required="" data-parsley-required-message="Please Enter Requested By Name" placeholder="Please Enter Requested By Name" data-value>

                                                    </div>
                                                </div>

                                                <div class="col-md-4 survey_b_location_other_c">
                                                    <div class="form-group error">
                                                        <label>Request Date:</label>
                                                        <input type="text" id="survey_date" name="survey_date" class="form-control datepicker"  placeholder="Please Enter Request Date" value="" >
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="col-md-4 survey_b_location_other_c">
                                                <div class="form-group">
                                                    <label>Client/Company:</label>
                                                        
                                                    
                                                    <input type="text" id="requested_by" name="requested_by" class="form-control common-control-red"  placeholder="Please Enter Client/Company Name" value="" required="" data-parsley-required-message="Please Enter Client/Company Name">
                                                    
                                                </div>
                                            </div>
                                            <div class="col-md-4 survey_b_location_other_c">
                                                <div class="form-group">
                                                    <label>Phone:</label>
                                                    <input type="text" id="client_phone" name="client_phone" class="form-control common-control-red"  placeholder="Please Enter Phone No" value="">
                                                    
                                                </div>
                                            </div>
                                            <div class="col-md-4 survey_b_location_other_c">
                                                <div class="form-group">
                                                    <label>Email:</label>
                                                    <input type="text" id="client_email" name="client_email" class="form-control common-control-red"  placeholder="Please Enter Email" value="">
                                                    
                                                </div>
                                            </div>
                                            
                                            
                                            <div class="col-md-12 invoice">
                                                <div class="form-group">
                                                    <label>Invoice Instructions:</label>
                                                    <input type="text" id="invoice" name="invoice" class="form-control invoice" placeholder="Please Enter Invoice Instruction" >
                                                    
                                                </div>
                                            </div>
                                            
                                            
                                            <div class="form-group">
                                                <div class="row-add-list">
                                                    <div class="row-add row control-group after-address">
                                                        <div class="col-md-12">
                                                            <div class="form-group add-plus">
                                                                <div class="plus">
                                                                    <a href="javascript:void(0)" class="add-more-address">
                                                                        <i class="ion-plus-circled"></i>
                                                                    </a>
                                                                </div>
                                                                
                                                                    <div class="col-md-12">
                                                                        <div class="form-group form-group-check">
                                                                            <div class="checkbox checkbox-info form-check-inline">
                                                                                <label for="inlineCheckbox1"> Send </label>
                                                                            </div>
                                                                            <div class="checkbox checkbox-info form-check-inline"> 
                                                                                <input type="checkbox" class='s_check_report' id="s_check_report_0" name='s_check_report'>
                                                                                <label for="s_check_report_0"> Reports And </label>
                                                                            </div>
                                                                            <div class="checkbox checkbox-info form-check-inline">
                                                                                <input type="checkbox"  class='s_check_invoice' id="s_check_invoice_0" name='s_check_invoice'>
                                                                                <label for="s_check_invoice_0"> Invoices To </label>
                                                                            </div>
                                                                        </div>
                                                                    </div>
                                                                </div>
                                                                <div class="col-md-12">
                                                                    <div class="form-group">
                                                                        <label>Company:</label>
                                                                        
                                                                            <div >
                                                                            <input type="text" id="s_company_0" name="s_company" class="form-control s_company"  placeholder="Please Enter Company Name" value="">
                                                                            </div>
                                                                    </div>
                                                                </div>
                                                                <div class="col-md-12">
                                                                <div class="form-group">
                                                                    <label>Address:</label>
                                                                    
                                                                    <div>
                                                                        <input type="text" id="s_address_0" name="s_address" class="form-control common-control-red s_address"  placeholder="Please Enter Address" value="">
                                                                    </div>
                                                                </div>
                                                                </div>

                                                            </div>
                                                        </div>
                                                        <div class="col-md-4 ">
                                                            <div class="form-group">
                                                                <label>City:</label>
                                                                <input type="text" id="s_city_0" name="s_city" class="form-control common-control-red s_city"  placeholder="Please Enter City" value="">
                                                                
                                                            </div>
                                                        </div>
                                                        <div class="col-md-4 ">
                                                            <div class="form-group">
                                                                <label>State:</label>
                                                                <input type="text" id="s_state_0" name="s_state" class="form-control common-control-red s_state"  placeholder="Please Enter State" value="">
                                                                
                                                            </div>
                                                        </div>
                                                        <div class="col-md-4 ">
                                                            <div class="form-group">
                                                                <label>Zipcode:</label>
                                                                <input type="text" id="s_zipcode_0" name="s_zipcode" class="form-control common-control-red s_zipcode"  placeholder="Please Enter Zipcode" value="">
                                                                
                                                            </div>
                                                        </div>
                                                        <div class="col-md-4 ">
                                                            <div class="form-group">
                                                                <label>Attention Of:</label>
                                                                <input type="text" id="s_attention_of_0" name="s_attention_of" class="form-control common-control-red s_attention_of"  placeholder="Please Enter Attention of" value="">
                                                                
                                                            </div>
                                                        </div>
                                                        <div class="col-md-4 ">
                                                            <div class="form-group">
                                                                <label>Phone:</label>
                                                                <input type="text" id="s_phone_0" name="s_phone" class="form-control common-control-red s_phone"  placeholder="Please Enter Phone No" value="">
                                                                
                                                            </div>
                                                        </div>
                                                        <div class="col-md-4 ">
                                                            <div class="form-group">
                                                                <label>Country Code:</label>
                                                                <input type="text" id="s_countrycode_0" name="s_countrycode" class="form-control common-control-red s_countrycode"  placeholder="Please Enter Country Code" value="">
                                                                
                                                            </div>
                                                        </div>
                                                        <div class="col-md-12 ">
                                                            <div class="form-group">
                                                                <label>Email:</label>
                                                                <input type="text" id="s_email_0" name="s_email" class="form-control common-control-red s_email"  placeholder="Please Enter Email" value="">
                                                                
                                                            </div>
                                                        </div>
                                                    </div>
                                                </div>
                                                <div class="address-append">

                                                </div>
                                            </div>
                                            <!-- <div class="col-md-12 survey_b_location_other_c">
                                                <div class="form-group">
                                                    <label>Address:</label>
                                                    <input type="text" id="address" name="address" class="form-control common-control-red"  placeholder="Please Enter address" value="">
                                                    
                                                </div>
                                            </div>
                                            <div class="col-md-4 survey_b_location_other_c">
                                                <div class="form-group">
                                                    <label>City:</label>
                                                    <input type="text" id="city" name="city" class="form-control common-control-red"  placeholder="Please Enter city" value="">
                                                    
                                                </div>
                                            </div>
                                            <div class="col-md-4 survey_b_location_other_c">
                                                <div class="form-group">
                                                    <label>State:</label>
                                                    <input type="text" id="state" name="state" class="form-control common-control-red"  placeholder="Please Enter state" value="">
                                                    
                                                </div>
                                            </div>
                                            <div class="col-md-4 survey_b_location_other_c">
                                                <div class="form-group">
                                                    <label>Zipcode:</label>
                                                    <input type="text" id="zipcode" name="zipcode" class="form-control common-control-red"  placeholder="Please Enter zip" value="">
                                                    
                                                </div>
                                            </div>
                                            <div class="col-md-4 survey_b_location_other_c">
                                                <div class="form-group">
                                                    <label>Attention Of:</label>
                                                    <input type="text" id="attention_of" name="attention_of" class="form-control common-control-red"  placeholder="Please Enter attention" value="">
                                                    
                                                </div>
                                            </div>
                                            <div class="col-md-4 survey_b_location_other_c">
                                                <div class="form-group">
                                                    <label>Phone:</label>
                                                    <input type="text" id="sent_phone" name="sent_phone" class="form-control common-control-red"  placeholder="Please Enter phone no" value="">
                                                    
                                                </div>
                                            </div>
                                            <div class="col-md-4 survey_b_location_other_c">
                                                <div class="form-group">
                                                    <label>Country Code:</label>
                                                    <input type="text" id="country_code" name="country_code" class="form-control common-control-red"  placeholder="Please Enter country code" value="">
                                                    
                                                </div>
                                            </div> -->
                                            <!-- <div class="col-md-12 survey_b_location_other_c">
                                                <div class="form-group">
                                                    <label>Email:</label>
                                                    <input type="text" id="sent_email" name="sent_email" class="form-control common-control-red"  placeholder="Please Enter email" value="">
                                                    
                                                </div>
                                            </div> -->
                                            
                                            <div class="col-md-4 survey_b_location_other_c">
                                                <div class="form-group">
                                                    <label>Date of Survey:</label>
                                                    <input type="text" id="survey_date1" name="survey_date1" class="form-control datepicker"  placeholder="Please Enter Date of Survey" value="" >
                                                </div>
                                            </div>
                                            <div class="col-md-4 survey_b_location_other_c">
                                                <div class="form-group">
                                                    <label>If Damage, Date of Loss:</label>
                                                    <input type="text" id="survey_date2" name="survey_date2" class="form-control datepicker"  placeholder="Please Enter Date of Loss" value="" >
                                                </div>
                                            </div>
                                            <div class="row" style="width:100%;overflow: hidden;">
                                                <div class='col-md-3 clearfix'>
                                                    <!-- <label class="d-block col-md-12 col-xs-12">&nbsp;</label> -->
                                                        <div class='pull-left m-l-15 m-r-10'>
                                                            <div class="form-group">
                                                                <div class="checkbox checkbox-primary">
                                                                <input type="checkbox" class='fleet_check' id="fleet_check" name='fleet_check' >
                                                                <label></label>
                                                                </div>
                                                            </div>
                                                        </div>
                                                        <div class='pull-left my_check_c right'>
                                                            <div class="form-group">
                                                                <div class="lbl-text lbl-text-check-gap">
                                                                    This is a fleet
                                                                </div>
                                                            </div>
                                                        </div>
                                                        <div class="clearfix"></div>
    
                                                </div>
                                                <div class="col-md-9 fleet_type">
                                                        <div class="form-group">
                                                            <label>Type of Fleet:</label>
                                                            <input type="text" id="fleet_type" name="fleet_type" class="form-control fleet_type" placeholder="Please Enter Type of Fleet" >
                                                            
                                                        </div>
                                                    </div>
                                            </div>
                                           
                                            <div class="col-sm-12 survey_b_location_other_c">
                                                <div>
                                                    <label>Survey Type:</label>
                                                    <div class="row">
                                                        <div class='col-md-3'>
                                                                <div class="form-group">
                                                            <select class="form-control survey_type" name="surveyor_type" id="surveyor_type" >
                                                                <option value="">Select Survey Type</option>
                                                                {% for survey_type in survey_request_options.Surveyor_Type %}
                                                                    <option value="{{survey_type.type_opt|capfirst}}" {% if survey_report_barge.survey_type|str_is_in:survey_type.id %} selected="selected" {% endif %}>
                                                                        {{survey_type.type_opt|capfirst}}
                                                                    </option>
                                                                {% endfor %}
                                                            </select>
                                                            </div>
                                                        </div>
                                                        <div class='col-md-9 survey_type_other' style="display:none">
                                                            <input type="text" id="survey_type_other" name="survey_type_other" class="form-control" placeholder="Enter Other Survey Type Here" value=''>
                                                        </div>
                                                        <div class='col-md-9 survey_type_fleet' style="display:none">
                                                            <!-- <label>Describe What This Fleet Consists Of</label> -->
                                                            <input type="text" id="survey_type_fleet" name="survey_type_fleet" class="form-control" placeholder="Describe What This Fleet Consists Of" value=''>
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                            
                                            <div class="col-md-12 survey_b_location_other_c">
                                                <div class="form-group">
                                                    <label>Survey Location (City, State):</label>
                                                    <input type="text" id="survey_location" name="survey_location" class="form-control"  placeholder="Please Enter Survey Location" value="">
                                                    
                                                </div>
                                            </div>
                                            <div class="col-md-12 survey_b_location_other_c">
                                                <div class="form-group">
                                                    <label>Assured We Represent:
                                                        <span class="info-circle"  data-container="body" title="" data-toggle="popover" data-placement="top" data-content="This is the Client/Company that we are working for (i.e. the people who are paying us)." data-original-title="" >
                                                                <i class="fa fa-info-circle text-info" aria-hidden="true"></i>
                                                        </span>
                                                    </label>
                                                    <input type="text" id="assured_rep" name="assured_rep" class="form-control"  placeholder="Please Enter Assured We Represent" value="">
                                                    
                                                </div>
                                            </div>
                                            <div class="col-md-12 survey_b_location_other_c">
                                                <div class="form-group">
                                                    <label>Asset We Represent:
                                                        <span class="info-circle"  data-container="body" title="" data-toggle="popover" data-placement="top" data-content="This is the vessel or structure that we are representing for the assured, even if we did not survey it (for example, we may represent &quot;Boat XYZ&quot;, which hit a dock that we are surveying)." data-original-title="" >
                                                            <i class="fa fa-info-circle text-info" aria-hidden="true"></i>
                                                        </span>
                                                    </label>
                                                    <input type="text" id="asset_rep" name="asset_rep" class="form-control"  placeholder="Please Enter Asset We Represent" value="">
                                                    
                                                </div>
                                            </div>
                                            <div class="col-md-12 survey_b_location_other_c">
                                                <div class="form-group">
                                                    <label>Asset Surveyed:
                                                        <span class="info-circle"  data-container="body" title="" data-toggle="popover" data-placement="top" data-content="This is the actual vessel or structure that is being surveyed.  (If we are surveying the dock that &quot;Boat XYZ&quot; hit, the description of the dock would go here).  In many cases this field will be the same as the &quot;Asset We Represent&quot;." data-original-title="" >
                                                                <i class="fa fa-info-circle text-info" aria-hidden="true"></i>
                                                        </span>
                                                    </label>
                                                    <input type="text" id="asset_survey" name="asset_survey" class="form-control"  placeholder="Please Enter Asset Surveyed" value="">
                                                    
                                                </div>
                                            </div>
                                            <div class="col-md-12 survey_b_location_other_c">
                                                <div class="form-group">
                                                    <label>Owner of Asset Surveyed:
                                                        <span class="info-circle"  data-container="body" title="" data-toggle="popover" data-placement="top" data-content="This is the company or owner of the specific item we are surveying. In many cases this field will be the same as the &quot;Assured We Represent&quot;." data-original-title="" >
                                                                <i class="fa fa-info-circle text-info" aria-hidden="true"></i>
                                                        </span>
                                                    </label>
                                                    <input type="text" id="own_asset_survey" name="own_asset_survey" class="form-control"  placeholder="Please Enter Owner of Asset Surveyed" value="">
                                                    
                                                </div>
                                            </div>
                                            <div class="col-md-12 survey_b_location_other_c">
                                                <div class="form-group">
                                                    <label>Survey Contact Info:</label>
                                                    <input type="text" id="contact_info" name="contact_info" class="form-control"  placeholder="Please Enter Survey Contact Info" value="">
                                                    
                                                </div>
                                            </div>
                                            
                                            <div class="col-md-6 survey_b_location_other_c">
                                                <div class="form-group">
                                                    <label>Quoted Amount:</label>
                                                    <input type="text" id="quoted_amount" name="quoted_amount" class="form-control"  placeholder="Please Enter Quoted Amount" value="">
                                                    
                                                </div>
                                            </div>
                                            
                                            <div class="col-md-6 survey_b_location_other_c">
                                                <!-- <div class="form-group"> -->
                                                    <label>Person Submitting This Request:</label>
                                                    <div class="form-group">
                                                        <select class="form-control survey_b_location" name="person_request" 
                                                        id="person_request" required="" data-parsley-required-message="Please Select">
                                                            <option value="">Select Person</option>
                                                            {% for survey in survey_request_options.Surveyor %}
                                                                <option value="{{survey.name|capfirst}}" {% if survey_report_barge.survey|str_is_in:survey.id %} selected="selected" {% endif %}>
                                                                    {{survey.name|capfirst}}
                                                                </option>
                                                            {% endfor %}
                                                        </select>
                                                    </div>
                                                <!-- </div> -->
                                            </div>
                                           
                                            <div class="col-md-12">
                                                <div class="form-group">
                                                    <label>Notes:</label>
                                                    <input type="text" id="ano_notes" name="ano_notes" class="form-control" 
                                                     placeholder="Please Enter Notes" value="">    
                                                    
                                                </div>
                                            </div>
                                            <input type="hidden" name="survey_id" id="dls_survey_id"
                                            value="{{survey_request.id}}">
                                            <div class="sra-cta-btn col-md-12">
                                                <button class="btn btn-primary send_mail" id="save" value="save" type="submit">Save</button>
                                                <button class="btn btn-primary pdf_download" type="button">Download Pdf</button>
                                                <button class="btn btn-primary pdf_download_new" type="button">Download Pdf</button>
                                                <button class="btn btn-primary new_button_survey_request new_button" id="save_mail" type="button" value="">
                                                    Submit Form
                                                </button>
                                                <span class="info-circle sign"  data-container="body" title="" data-toggle="popover" data-placement="top" data-content="Submitting this form will send an email notification to the dictation inbox, notifying our administrative staff to open the job in Juris." data-original-title="" >
                                                    <i class="fa fa-info-circle text-info" aria-hidden="true"></i>
                                                </span>
                                                <button class="btn btn-primary new_button_survey_request1" id="save_mail" type="button" value="">
                                                    Submit Form
                                                </button>
                                                <span class="info-circle sign1"  data-container="body" title="" data-toggle="popover" data-placement="top" data-content="Submitting this form will send an email notification to the dictation inbox, notifying our administrative staff to open the job in Juris." data-original-title="" >
                                                    <i class="fa fa-info-circle text-info" aria-hidden="true"></i>
                                                </span>
                                                
                                            </div>


                                           

                                            
                                        </form>
                                        

                                    </div>




                                </div>
                            </div>

                        </div>
                    </div>
                </div>
            </div>
        </div>
    </div>
</div>


<!-- Client add model start -->
<div class="modal fade" tabindex="-1" role="dialog" id="addClientForm" >
    <div class="modal-dialog" role="document">
      <div class="modal-content">
        <div class="modal-header">
            <button type="button" class="close" data-dismiss="modal" aria-hidden="true">×</button>
            <h4 class="modal-title" id="custom-width-modalLabel">Add Client</h4>
        </div>
        <form  name='newclientByModal' id='newclientByModal' method='POST' action='' novalidate='' enctype='multipart/form-data'>
            <div class="modal-body">

                <div class='col-md-12 finding-check-wrapper clearfix'>
                    <label class="d-block col-md-12">&nbsp;</label>
                    <div class='col-md-1 left'>
                        <div class="form-group">
                            <div class="checkbox checkbox-primary">
                            <input type="checkbox" class='new_contact' id="new_contact" name='new_contact' >
                            <label></label>
                            </div>
                        </div>
                    </div>
                    <div class='col-md-11 my_check_c right'>
                        <div class="form-group">
                            <div class="lbl-text">
                                This is a new contact for an existing client in Juris
                            </div>
                        </div>
                    </div>
                </div>

                <div class="form-group">
                    <label>Company Name</label>
                    <input type="text" id="name" name="name" class="form-control"  placeholder="Please enter company Name" value="">
                </div>
                <div class="form-group">
                    <label>Contact Name</label>
                    <input type="text" id="contact" name="contact" class="form-control"   required="" data-parsley-required-message="Please enter Contact name" placeholder="Please enter Contact name" value="">
                    
                </div>
                <div class="form-group">
                    <label>Phone</label>
                    <input type="text" id="phone" name="phone" class="form-control"  placeholder="Please enter phone" value="">
                    
                </div>
                <div class="form-group">
                    <label>Fax</label>
                    <input type="text" id="fax" name="fax" class="form-control"  placeholder="Please enter fax" value="">
                    
                </div>
                <div class="form-group">
                    <label>Address</label>
                    <input type="text" id="address" name="address" class="form-control" placeholder="Please enter address" value="">
                    
                </div>
                <div class="form-group">
                    <label>City</label>
                    <input type="text" id="city" name="city" class="form-control"  placeholder="Please enter city" value="">
                    
                </div>
                <div class="form-group">
                    <label>State</label>
                    <input type="text" id="state" name="state" class="form-control"  placeholder="Please enter state" value="">
                    
                </div>
                <div class="form-group">
                    <label>Zipcode</label>
                    <input type="text" id="zip" name="zip" class="form-control"  placeholder="Please enter zip" value="">
                    
                </div>
                <div class="form-group">
                    <label>Country</label>
                    <input type="text" id="country" name="country" class="form-control"  placeholder="Please enter country" value="">
                    
                </div>
                <div class="form-group">
                    <label>Email</label>
                    <input type="text" id="email" name="email" class="form-control"  placeholder="Please enter email" value="">
                    
                </div>
                <div class="form-group text-right">
                    <div>
                        <button type="submit" class="btn btn-primary waves-effect waves-light upload-contracts-excel-files current-client-add"> Submit </button>
                        <button type="submit" class="btn btn-primary waves-effect waves-light upload-contracts-excel-files current-client-please-wait" style="display: none;" dictsort> Please wait </button>
                    </div>
                </div>
            </div>
        </form>
      </div>
    </div>
  </div>
<!-- Client add model end -->

{% endblock %}