/**
 * /app/views/certificate_holder_form.php
 */

require_once dirname(__DIR__) . '/config/config.php';

$isEdit = isset($holder['id']) && !empty($holder['id']);
$formTitle = $isEdit ? 'Edit Certificate Holder' : 'Add Certificate Holder';
$formAction = $isEdit
    ? "certificate_holder_update.php?id=" . (int)$holder['id']
    : "certificate_holder_store.php";

include dirname(__DIR__) . '/views/partials/header.php';
?>

<div class="container-fluid">

    <div class="row">

        <div class="col-md-12">

            <div class="card shadow-sm border-0">

                <div class="card-header bg-white">
                    <h4 class="mb-0"><br />
<b>Warning</b>:  Undefined variable $formTitle in <b>/home/hostgatoren/coi.johnmarshallinsurance.com/app/views/certificate_holder_form.php</b> on line <b>25</b><br />
<br />
<b>Deprecated</b>:  htmlspecialchars(): Passing null to parameter #1 ($string) of type string is deprecated in <b>/home/hostgatoren/coi.johnmarshallinsurance.com/app/views/certificate_holder_form.php</b> on line <b>25</b><br />
</h4>
                </div>

                <div class="card-body">

                    <form method="POST" action="<br />
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<br />
<b>Deprecated</b>:  htmlspecialchars(): Passing null to parameter #1 ($string) of type string is deprecated in <b>/home/hostgatoren/coi.johnmarshallinsurance.com/app/views/certificate_holder_form.php</b> on line <b>30</b><br />
">

                        <div class="row">

                            <div class="col-md-6 mb-3">
                                <label class="form-label">Company Name *</label>
                                <input type="text" name="company_name"
                                       class="form-control"
                                       value=""
                                       required>
                            </div>

                            <div class="col-md-6 mb-3">
                                <label class="form-label">Email *</label>
                                <input type="email" name="email"
                                       class="form-control"
                                       value=""
                                       required>
                            </div>

                        </div>

                        <div class="mb-3">
                            <label class="form-label">Address 1</label>
                            <input type="text" name="address1"
                                   class="form-control"
                                   value="">
                        </div>

                        <div class="mb-3">
                            <label class="form-label">Address 2</label>
                            <input type="text" name="address2"
                                   class="form-control"
                                   value="">
                        </div>

                        <div class="row">

                            <div class="col-md-4 mb-3">
                                <label class="form-label">City</label>
                                <input type="text" name="city"
                                       class="form-control"
                                       value="">
                            </div>

                            <div class="col-md-4 mb-3">
                                <label class="form-label">State</label>
                                <input type="text" name="state"
                                       class="form-control"
                                       value="">
                            </div>

                            <div class="col-md-4 mb-3">
                                <label class="form-label">Zip Code</label>
                                <input type="text" name="zip"
                                       class="form-control"
                                       value="">
                            </div>

                        </div>

                        <div class="mt-4 d-flex gap-2">

                            <button type="submit" class="btn btn-primary">
                                Save Certificate Holder
                            </button>

                            <a href="certificate_holders.php" class="btn btn-secondary">
                                Cancel
                            </a>

                        </div>

                    </form>

                </div>

            </div>

        </div>

    </div>

</div>


    </div> <!-- end container / page wrapper -->

    <footer class="bg-light border-top mt-5 py-3">
        <div class="container text-center text-muted small">
            COI Generator v1 &copy; 2026 - Internal Use Only
        </div>
    </footer>

    <!-- Bootstrap JS -->
    <script src="https://cdn.jsdelivr.net/npm/bootstrap@5.3.3/dist/js/bootstrap.bundle.min.js"></script>

</body>
</html>